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Fifteen-minute consultation: Vaccine-hesitant parents
  1. Helen E Bedford1,
  2. David A C Elliman2
  1. 1 Great Ormond Street Institute of Child Health, UCL, London, UK
  2. 2 Great Ormond Street Hospital for Children, London, UK
  1. Correspondence to Professor Helen E Bedford, Great Ormond Street Institute of Child Health, UCL, London WC1N 1EH, UK; h.bedford{at}ucl.ac.uk

Abstract

Vaccination is a proven, highly effective intervention to protect against potentially serious infectious diseases. UK vaccine uptake rates are high overall, but considerable variation exists within and between districts. The main reason for under vaccination is difficulty accessing vaccination services for practical or logistical reasons. While some parents decline specific vaccines, only a small minority decline them all. It is unsurprising that many parents have questions about vaccination, but most are easily addressed. This article provides practical guidance on how to engage effectively with parents with the ultimate aim of supporting informed vaccination decisions. The focus will be on conversations with parents whose concerns make them unsure whether to accept vaccination or who have previously delayed or declined vaccines. In view of recent outbreaks of measles, the example question concerns MMR (measles, mumps and rubella) vaccine. Although conversations with some parents, especially those who are determinedly anti-vaccine, can be uncomfortable, even challenging, it is important to offer all parents the opportunity to discuss their concerns. Even though advice may go unheeded or even be unwelcome, parents can change their minds about previous decisions. Health professionals and the National Health Service are trusted sources of advice about vaccinations and have a responsibility to ensure parents are appropriately informed.

  • vaccine
  • hesitant
  • parent

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Introduction

Vaccination is a highly effective intervention against potentially serious infectious diseases. In the UK, the childhood vaccination schedule currently comprises vaccines offered routinely to protect against 14 diseases by school entry with MenACWY (meningococcal ACWY), human papillomavirus (HPV) and a booster (Td/IPV (tetanus, diphtheria and polio)), offered in adolescence.1 Changes to the schedule are frequent and include the introduction of new vaccines or alterations made to the number or timing of doses of existing vaccines. The most recent was the inclusion of universal hepatitis B vaccine in 2017. From September 2019, HPV vaccine will be offered to boys aged 12–13 years.

Vaccine uptake in the UK is generally high with over 90% of 12 month olds and 24 month olds fully vaccinated with the primary vaccines and MMR (measles, mumps and rubella), respectively2; however, geographical variation in uptake persists. The majority of infants who have not completed the primary vaccine course by 12 months of age will be partially vaccinated rather than completely unvaccinated3 with many catching up by 24 months.2 Quarterly vaccine coverage data show a gradual decline of 2.7% in MMR uptake at 24 months in the UK between the beginning of 2014 and the end of 2018. This decline is a cause for concern and although the reason is not clear it is likely to be multifactorial. There is no specific evidence of a decline in vaccine confidence, indeed the most recent attitudinal study of over 1600 parents of under 4 year olds, conducted by Public Health England reported vaccine confidence to be high .4

Large measles outbreaks currently occurring globally underline the importance of maintaining high vaccine uptake. In England, there were 966 confirmed cases of measles in 2018 compared with 297 in 2017.5 The underlying reasons for these outbreaks differ between countries. In the UK, a large contribution is gaps in immunity in older adolescents, resulting from reduced uptake in the early 2000s due to public fears over the safety of MMR vaccine. In the UK, the most important reasons for under vaccination of current cohorts are difficulties accessing services for practical or logistical reasons; vaccine refusal has a small part to play. Children at risk of being under vaccinated are shown in box 1.

Box 1

Children at risk of being under vaccinated

  • Children in large families

  • Children with lone or young parents

  • Looked after children

  • Children in mobile families

  • Migrant/asylum-seeking children

  • Children with disabling or chronic conditions

  • Children in some ethnic minority groups

  • Children whose parents decline vaccination—vaccine refusal varies between vaccines—only a small proportion of parents, about 1%–2% in the UK, refuse all vaccines for their children

In 2019, the WHO declared ‘vaccine hesitancy’ to be one of the 10 threats to global public health.6 Defined as ‘delay or refusal of vaccine in the presence of services’, it has been suggested that the increasingly loud antivaccine sentiment on social media has contributed to increasing ‘vaccine hesitancy’ in some parts of the world.7 Since such misinformation spreads rapidly and widely, there is an even greater need for health professionals to be equipped to discuss parents’ concerns and to advocate for vaccination. While all health professionals have a part to play, paediatricians’ and other child health professionals’ advice may be particularly valuable. Their experience of caring for children with infectious diseases provides them with particular insights into the seriousness of the diseases. They also have contact with children who may be both less likely to be fully vaccinated, but also at greater risk of the consequences of not being vaccinated and in need of extra vaccines due to chronic health conditions. For example, uptake of influenza vaccine in at-risk children is low. Only 20% of children aged between 6 months and 2 years with neurological problems received influenza vaccine in 2017/2018.8

What questions and concerns do parents have about vaccines?

Public mistrust in vaccines has a history as long as that of vaccination. However, as successful programmes have reduced the threat of disease and programmes have expanded, the nature of vaccine concerns and their dissemination have changed. Therefore, it should not be surprising that many parents have questions about vaccines and, indeed, these should be encouraged to ensure that parents can make a fully informed choice. Examples of common questions about vaccines (box 2) are gathered from a combination of our clinical experience in specialist vaccination advisory clinics, of discussing immunisation with parents, of teaching primary care staff, of our research and from the literature.

Box 2

Common questions and concerns about vaccination

  • Vaccine safety in general

  • Side effects of specific vaccines

  • The need for vaccination in an era of low disease incidence

  • How well vaccines work? (eg, natural immunity ‘better’)

  • The effects of giving so many vaccines at one time (vaccine overload)

  • Vaccine ingredients (eg, mercury in past, aluminium currently)

  • MMR (measles, mumps and rubella) vaccine and links with autism

  • Giving vaccines at a young age

The need for and value of vaccination conversations

Vaccine decision-making is complex with multiple influencing factors. However, as health professionals are an important and trusted source of advice, they have an major role in discussing vaccination with parents.9

As parents often report that not enough information is provided or that their questions are not answered properly,10 there is a clear need to provide parents with the opportunity to discuss vaccination. Information should be offered in advance of the vaccination appointment and may need to be offered again taking into account any media stories or new questions parents may have. Depending on the parents’ vaccination position—unquestioning acceptor, cautious acceptor, hesitant, late or selective acceptor, or refuser11 parents will be at varying degrees of readiness to vaccinate, making some vaccine conversations challenging, even uncomfortable, leading to a temptation, by professionals and parents, to avoid such interactions.

Despite a current lack of evidence from high-quality trials of successful strategies for communicating with vaccine-hesitant parents,12 other evidence9 13 and our own experience suggests that an effective interaction can positively influence a parent’s view of vaccines. Talking with parents about vaccination is time well spent.

Engaging with parents’ concerns

The reasons for vaccine refusal or delay are often complex and do not arise simply from a knowledge deficit, so filling a ‘knowledge gap’ by giving large amounts of information may not be successful in itself and could even be counterproductive. Box 3 describes a typical scenario.

Box 3

Scenario

  • Poppy is a 3-year old attending your outpatient department for severe asthma. On taking a history, her parents tell you that she completed her primary course of vaccines at 8, 12 and 16 weeks, the boosters at 12 months, but has not had the MMR (measles, mumps and rubella) vaccine due at 12/13 months.

  • On further discussion, the parents explain that they refused MMR vaccine as Poppy’s elder brother developed autism following his first MMR vaccination.

The aim of the conversation is to gain parents’ trust and support them in making a decision with which they feel comfortable, ideally vaccine acceptance. It is not intended that all the information provided here would be given to all parents, as it is key that conversations are tailored to the parents’ particular concerns and information needs. While it is important that health professionals are well informed, the approach taken in the conversation is critical. Below, we describe the principles of the vaccination conversation (informed by Leask et al)11 in box 4.

Box 4

Principles of the vaccination conversation

  • The overall aim is to gain the parents’ trust.

  • Begin by asking permission to discuss Poppy’s vaccinations. Raising the subject gives the message that this is important and also gives her parents permission to ask questions.

  • Ask questions to gain greater insight into the parents’ main concerns and listen to them.

  • Be empathic, ‘I understand why you might be concerned’ it really is not surprising that parents have questions and concerns.

  • Avoid giving a fact-filled lecture, simply giving more and more information is not the solution.

  • Stick to the concerns raised and provide a limited number of main points in response, expressed simply.

  • Focus on the risk of the diseases—the public, and some professionals, have little experience of diseases because of the success of the vaccination programme.

  • There is evidence that restating a myth serves to reinforce it— instead identify a myth as being false and focus on the facts: the benefits of vaccination while acknowledging the side effects of vaccines.

  • Highlight the consensus among scientists/health professionals about the evidence in support of vaccination.

  • Acknowledge that we all want the best for their children.

  • Do not belittle parents’ concerns.

  • If parents decide not to vaccinate, be clear they can change their mind at any stage and leave the door open for further discussion.

  • If asked whether you have vaccinated your own children, confirming that you have is an important exemplar.

Decades of low measles incidence resulting from high vaccine uptake means that many parents will have no experience of the disease, which has a significant complication rate. MMR is highly effective and safe with serious adverse reactions uncommon and much less frequent than the complications of natural infection which occur in about 1 in 15 cases (tables 1 and 2).

Table 1

Complications of measles

Table 2

The MMR vaccination programme. Vaccine schedule, contraindications and adverse reactions

Concerns over a possible association between MMR vaccine, autism and bowel disease were ignited following a subsequently retracted 1998 Lancet publication (box 5).

Box 5

Evidence of no link between MMR (measles, mumps and rubella) and autism

  • A small case series of 12 children with autism or regressive developmental disorder and bowel conditions suggested a new syndrome.

  • In 8/12 of these children, it was reported that their symptoms came on soon after MMR vaccine was given.

  • The authors concluded that they had not proven an association between the vaccine and the new syndrome described and they suggested more research was needed.16

  • An accompanying commentary highlighted the reasons why this study did not provide sound evidence of a link.17

  • However, the lead author did then, and continues to, claim a link.

  • Sound research conducted subsequently in many countries has found evidence of no link between vaccines and the development of autism. This includes a meta-analysis of five cohort and case–control studies including over 1 million children.18

  • Another more recent study including over 0.5 million Danish children with over 5 million person-years of follow-up and 6517 children diagnosed with autism showed no link.19

  • In addition, there is solid evidence, that having a sibling with autism does not predispose to autism after MMR vaccine.19,20

Despite the lack of sound evidence for a link and the strength of scientific evidence showing no link between any vaccine and autism, this may not be convincing for parents of a child with autism or reassuring for parents who are undecided about accepting the vaccine. As the signs of autism are often first recognised at about 18 months of age, a time when vaccines are also given, this may seem to provide an explanation for the cause of their child’s condition. Anecdotes about events surrounding the onset of a condition seem to have a particular influence on perceptions, indeed it has been suggested that in the absence of evidence that vaccines cause serious harm, antivaccine activists have relied on the power of such anecdotal evidence to undermine public confidence in vaccination.14 In the same way, telling stories about children who have suffered the effects of a vaccine preventable disease in addition to evidence-based information included here could be a powerful way of communicating the benefits of vaccination.

Conclusions

In the UK, it is the norm for children to be vaccinated. However, some children are not immunised on time for practical reasons and this needs to be addressed by reminding parents and providing accessible, flexible services. Some parents have questions and concerns and should have the opportunity to discuss these with a knowledgeable and empathetic health professional. If after such discussion, the decision to vaccinate is not made, it should be emphasised that the door remains open for future discussion as it is never too late to vaccinate. This opportunity should also be offered to the small minority of parents who resolutely object to their children being immunised.

Box 6

Sources of information to support immunisation conversations

Websites

Publications

  • Although this series of papers is now dated, they remain a useful resource.

  • Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, et al. Addressing parents' concerns: do multiple vaccines overwhelm or weaken the infant's immune system? Pediatrics 2002;109:124–9.

  • Offit PA, Hackett CJ. Addressing parents' concerns: do vaccines cause allergic or autoimmune diseases? Pediatrics 2003;111:653–9.

  • Offit PA, Jew RK. Addressing parents' concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics 2003;112:1394–7.

  • Offit PA, Coffin SE. Communicating science to the public: MMR vaccine and autism. Vaccine 2003 ;22:1–6.

Test your knowledge (tick all that apply)

  • The first dose of MMR vaccine is routinely offered in UK at

    1. 15 months

    2. 18 months

    3. 3 years 4 months

    4. 12 months

  • The following are genuine contraindications to MMR vaccine (tick all that apply)

    1. Pregnancy

    2. Egg allergy

    3. Immunosuppression

    4. Asthma

  • The rate of anaphylaxis after MMR vaccine is

    1. 1 in 1000

    2. 1 in 10,000

    3. 1 in 30,000

    4. 1 in 100,000 – 1,000,000

  • Adverse effects of MMR vaccine are: (tick all that apply)

    1. Autism

    2. Fever

    3. Parotid swelling

    4. Convulsions

  • MMR vaccine

    1. Is a conjugate vaccine

    2. Contains live attenuated measles, mumps and rubella viruses

    3. Is a killed vaccine

    4. Requires two doses for optimal protection

  • Answers to the quiz are at the end of the references.

Answers to the multiple choice questions

  • D.

  • A; C.

  • D.

  • B; C; D.

  • B; D.

References

Footnotes

  • Contributors HEB and DACE contributed equally to writing this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.