Vaccine Hesitancy and Refusal:
Addressing Concerns and
Promoting High Immunization Rates
Ailis Clyne, MD, MPH, FAAP
Medical Director, Div CFHE
Rhode Island Department of Health
Importance of Vaccines
The current routine childhood immunization schedule is
estimated to:
– Prevent 42,000 deaths
– Prevent 20 million cases of disease
– Save $14 billion in direct medical costs
Per US birth cohort
Zhou F, Shefer A, Wenger J, et al., Economic evaluation of the routine childhood immunization program in the United States,
2009. Pediatrics. 2014; 133(4):577–585
The success of vaccines in reducing disease-associated
mortality is second only to the introduction of safe
drinking water
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA
statement. Int J Surg2010;8(5):336–41
Impact of HPV Vaccination
Currently 26 million girls <13 yo in the US; If none
of these girls are vaccinated then:
168,400 will develop cervical cancer and
54,100 will die from it
 Vaccinating 30% would
prevent 45,500 of these
cases and 14,600 deaths
 Vaccinating 80% would
prevent 98,800 cases
and 31,700 deaths
RI Immunization Rates
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Rhode Island childhood and adolescent immunization rates are among
the highest in the country
Exemptions for school mandated vaccines are quite low: 1.1% for
Kindergarten and 0.6% for 7th grade (2012-2013)
Influenza Vaccine: Rhode Island had the highest coverage rate in the
nation for the influenza vaccination among children 6 months through 17
years of age with a 74.5% during the 2013-2014 influenza season.
Children: Rhode Island had the highest coverage rate in the nation for
the 4:3:1:3:3:1:4 series (4DTaP, 3 Polio, 1MMR, 3 HepB, 3 Hib, 1
Varicella, 4 PCV) among children 19-35 months of age with an 82.1% in
2013.
Adolescents: Rhode Island had the highest coverage rates in the nation
for the 1+ Tdap vaccine (95.5%) and 3+ HPV vaccine for females
(56.5%) and males (43.2%) among adolescents 13- 17 years of age in
2013.
RI Immunization Rates
Vaccine Hesitancy
Categorizing Vaccine Hesitancy
• Gust et. al.: 5 categories of VHP based
on perceived necessity and safety
– Immunization Advocates (33%)
– Go Along to Get Alongs (26%)
– Health Advocates (25%)
– Fence Sitters (13%)
– Worrieds (3%)
• Leask et. al.: categories of all parents
– Unquestioning Acceptor
– Cautious Acceptor
– Hesitant
– Late/Selective
– Refuser
Assessing Vaccine Hesitancy
Parent Attitudes about Childhood Vaccines Survey
Opel DJ, Mangione-Smith R, Taylor JA, et al.
Development of a survey to identify vaccine
hesitant parents: the Parent Attitudes about
Childhood Vaccines survey. Hum Vaccin. 2011;
7(4):419–425
Factors Influencing Vaccine Hesitancy
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Racial/ethnic disparities
Lower income level associated with
reporting not having enough vaccine
information
Refusal of all vaccines more common
among college educated parents.
• Immediate or short term effects: pain, fever,
redness, swelling
• Long term effects concerns: autism, GBS
• Omission bias: prefer the consequences of doing
nothing to the consequences of doing something
• Number of vaccines: pain, side effects when
receiving multiple vaccines, immunologic
overload
• Lack of personal experience with the disease
leads to an underestimation of the severity of the
disease
Charitha Gowda and Amanda F DempseyHuman Vaccines &
Immunotherapeutics 9:8, 1755–1762; August 2013F Dempsey2,
• Vaccine refusers- less emphasis on
providers’ recommendations when making
healthcare decisions
• School mandated vaccine policies
significantly increase vaccine coverage levels
• Media: tailored messaging based on level of
vaccine hesitance, finding a celebrity vaccine
champion
Images and Social Media
Vaccine Hesitancy and Refusal:
Common Themes
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Safety / “new”
Perceived associations with specific conditions
Unnecessary
Parental autonomy to make vaccine decisions
Efficacy
Unnatural
Non-standard vaccine schedules
Non-standard vaccine schedules
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Pediatrics April 2015
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Survey of 534 of pediatricians and
family physicians in 2012
87%-parents were putting their
children at risk for disease
84%-alternative schedules are
more painful for children
82%-agreeing to requests for nonstandard schedules builds trust
with families
80%-parents might leave the
practice if a non-standard schedule
request is declined
Providers agreed to spread out
vaccines:
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Often/always 37%
Sometimes 37%
Providers discharge families from
the practice
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Often/always 2%
Sometimes 4%
Rarely 12%
Addressing vaccine hesitancy and refusal
Vaccine refusal not only
increases the individual risk of disease but also
increases the risk for the whole community
Message Framing
Pediatrics September 2014
What’s Recommended?
• Understanding parental concerns
• Establish honest dialogue
• Acknowledge that vaccines may be associated
with adverse events and balance that against
disease risk
• Address specific vaccine concerns
• Provide other information resources
• Ensure ongoing communication
• The AAP Committee on Bioethics does not
recommend discontinuing care for families who
refuse or delay immunization
What Works?
Vaccine 2013
• Literature review July-September
2012 including 30 studies
1. Passage of state laws
2. State and school level
implementation of laws
3. Parent-centered information or
education --> brochures,
pamphlets, posters, parent
meeting, radio, power point,
web-based decision aid
1. "The introduction of philosophical/personal
exemptions in states consistently showed an
increase in non-medical exemption rates.“
2. "...decreased exemption rates with early and
frequent notification of parents for school entry
immunization requirements“
3. "Our systematic review did not reveal any
convincing evidence on effective interventions to
address parental vaccine hesitancy and refusal"
Legal Basis For School
Immunization Requirements
• 1809: Massachusetts passed a law requiring small pox vaccine
to prevent and control frequent smallpox outbreaks that had
substantial health and economic consequences
• 1905: Jacobson v. Massachusetts  US Supreme Court
endorsed the rights of states to pass and enforce compulsory
vaccination laws.
• 1922: Zucht v. King  US Supreme court find school
immunization requirements to be constitutional
Vaccine Exemptions
Communication Strategies
Effective messages in vaccine promotion
AUTHORS: Brendan Nyhan, PhD,a Jason
Reifler, PhD,b Sean Richey, PhD,c and Gary L. Freed, MD, MPHd,e, Pediatrics 2014
•Phone survey of 1759 US parents
•Survey of attitudes towards vaccines
•Randomly assigned to 1 of 4 pro-vaccine messages or control
1.
Correcting misinformation-MMR vaccine and autism
2.
Presenting information on disease risks-symptoms of MMR, adverse events
after vaccine-MMR VIS
3.
Using dramatic narratives-CDC narrative of mother's recounting of infant son
with measles hospitalization
4.
Displaying visuals-pictures of a child with each disease
•Post message survey
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vaccines and autism
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vaccines and side effects
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likelihood of giving MMR vaccine to a future child
Communication Strategies
• None of the 4 interventions increased intent to vaccinate
among parents who are the least favorable towards
vaccines
• Corrective information from the CDC website successfully
corrected misperceptions about MMR causing autism but
also reduced vaccination intent among parents with least
favorable vaccine attitudes
• Both the dramatic narrative and images of sick children
increased misperceptions of MMR vaccine
• Importance of testing health messages for effectiveness
before dissemination
Communication Strategies
Presumptive: (74% of providers)
“Well, we have to do some shots.”
“So, we’ll do 3 shots and the drink, is this okay?”
26% of parents resisted vaccines
Participatory: (26% of providers)
“Are we going to do shots today?”
“What do you want to do about shots?”
“You’re still declining shots?”
83% of parents resisted vaccines
Provider does not pursue:
“Okay”
“We could split them up”
“We could do them when you come back in 2 months”
Provider pursues vaccine recommendation: (50%)
“He really needs these shots”
“Whooping cough can be a killer in the kid under 1”
47% of parents who were resistant agree to vaccines
Pediatrics 2013
AUTHORS: Douglas J. Opel, MD, MPH, John Heritage,
PhD, James A. Taylor, MD, Rita Mangione-Smith, MD,
MPH, Halle Showalter Salas, MPhil, Victoria DeVere,
BS,Chuan Zhou, PhD, and Jeffrey D. Robinson, PhD
Vaccine Information Resources
Vaccine Information Resources
http://www.cdc.gov/vaccines/
http://www.immunize.org/
http://vec.chop.edu/service/vaccine-education-center/home.html
https://www.iom.edu/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety.aspx
Measles Vaccine Resource
HPV Vaccine Resources
http://www.cdc.gov/vaccines/who/
teens/for-hcp-tipsheet-hpv.pdf
HPV Vaccine Resources
Ailis Clyne MD, MPH
Medical Director
Division of Community, Family Health, and Equity
401.222.5928
Ailis.clyne@health.ri.gov
www.health.ri.gov