A new nationwide analysis has revealed that the majority of U.S. pediatricians abide by a policy of turning away patients who refuse to vaccinate their children. The findings come on the heels of California’s ongoing measles outbreak, which has renewed a broader dialogue over vaccine policy, making doctors’ approach to the issue a national concern.
The study, conducted by data analyst Chip Hart of the Vermont-based Physicians Computer Company (PCC), found that 54 percent of the nearly 500 practices surveyed have some vaccine requirement, and will refuse treatment to parents who don’t comply.
Writing about the findings in a blog post, Hart said he was surprised the numbers were that high. “I have to admit that my guess put it at [about] 35-40 percent,” he said. But based on the results, he wrote, “I feel safe saying that vaccination requirements are the norm.”
PCC describes themselves as a consulting firm for pediatricians. For more than three decades, the company has offered services to help doctors with a variety of important data management tasks, including tracking vital issues like immunization rates. This pre-existing network of doctors allowed Hart to mail his survey out to roughly 5,000 pediatricians across the country, of which 497 responded (that’s about average for a mail survey).
“Although it’s possible that we have some selection bias,” he acknowledged, “I think we’ve got a pretty good spread of pediatric practices in the results.”
Fifty shades of vaccine refusal
Since at least one traveler infected with measles visited Disneyland during the year-end holidays, California has been dealing with an outbreak that has resulted in 123 cases across 12 counties, at least 39 of which have been directly linked to the theme park. The spread of the disease has put the spotlight back on parents who refuse immunizations for their kids — people who believe the shots aren’t safe, and who often cite the thoroughly debunked conspiracy theory that vaccines are linked to autism.
Those parents, typically disparagingly referred to as “anti-vaxxers,” are at the extreme end of the spectrum. Most American adults support vaccine requirements, and it’s actually very rare for kids to enter school without getting any shots at all. According to one 2009 study published in the New England Journal of Medicine, just two percent of the population refuses vaccines altogether.
But that doesn’t mean that anti-vaccine sentiments are rare. Although the group that most Americans thinks of as “anti-vaxxers” may be small, there’s actually a much larger group of vaccine skeptics that flies more under the radar. A growing number of parents are delaying their kids’ vaccines, opting to make up their own schedule rather than strictly adhering to the federal government’s recommended schedule for childhood immunization.
These adults don’t necessarily think of themselves as conspiracy theorists along the lines of Jenny McCarthy. Indeed, many of them firmly reject the anti-vaxxer label. But medical experts say their views are just as anti-science as the idea that vaccines cause autism — and potentially very dangerous to public health.
Like unfounded concerns over vaccines’ link to autism — which were stoked by a discredited researcher named Andrew Wakefield — theories about the issues with the CDC’s vaccination schedule largely originate from one public figure with a questionable scientific background. Dr. Robert Sears, who has not personally conducted any research into vaccines, argues that parents should space out vaccines over 21 visits, instead of the 13 recommended by the government, to ease the potential burden on babies’ immune systems.
That may sound logical to parents who are worried that adverse effects may arise from giving their kids multiple shots at once. But there’s absolutely no scientific evidence to back it up. Sears’ alternative vaccination schedule — which he has admitted he simply made up — has been discredited by pediatricians, researchers, and an expansive (and still growing) body of medical research.
Although it’s hard to estimate exactly how many parents are going against the CDC’s recommendations and spacing out their kids’ shots, one 2011 study estimated that it could be as many as 30 percent. Another study published the same year found that one in ten parents are following an alternative schedule. According to federal researchers, one child out of every 12 is not receiving their first dose of the measles vaccine on time.
Vaccine exemptions are a ‘tragedy of the commons’
With pockets of under-immunization now contributing to the rise of vaccine-preventable diseases in communities across the country, some legislators are looking to policy solutions to overcome the problem. In California, for instance, lawmakers have proposed tightening the state’s personal belief exemptions for childhood vaccines. As it currently stands, parents in this state are able to enroll their children in school without immunizations if they can first prove they’ve visited a doctor. Exceptions are also made based on religious beliefs.
Nationally, the rate of non-medical vaccine exemptions has jumped by 37 percent in just the past four years, with 48 states currently permitting exemption based on religion and 20 offering broader grounds to seek exemption based on philosophical or moral reasons. Research has shown that vaccination rates are significantly lower in states with broader exemption criteria. Not surprisingly, rates of vaccine-preventable diseases are also far higher in these states — according to one study, states with lax exemption policies have whooping cough rates up to 90 percent higher than states with more rigorous exemption criteria.
The maps below, by Mother Jones, show the clear overlap between state vaccine exemption criteria and rates of non-medical vaccine exemption:
When individual parents opt out of vaccinations for their children, they put their entire community at risk. To be effective, vaccinations must create herd immunity, which is when the vaccination of a significant portion of a population provides a measure of protection for individuals who have not developed immunity. If a large enough percentage of the population is vaccinated, individuals who are too young, too ill or unwilling to be immunized will still be protected from diseases. When a large enough number of people choose to forgo immunization, though, herd immunity starts to break down, letting disease spread.
Already the consequences of herd immunity breakdown are showing. Take measles, for instance. Measles used to affect 3 million people and kill 500 children annually in the U.S., but it was declared to be eliminated in 2000 and reduced to an average of barely 200 cases annually thanks to vaccine use. Last year, when the number of vaccine opt-outs increased nationwide, the number of measles cases skyrocketed to 644. And now, in just the first six weeks of 2015, more than 150 cases of measles have already been confirmed in 17 states across the country.
Given the clear evidence showing that vaccine exemption policies pose a danger to public health (not to mention the burden on taxpayers), many medical and legal experts say legislative action is urgently needed and ethically mandated. Lawrence O. Gostin, a law professor and one of the world’s leading health law scholars, made that case in a recent article in JAMA Online:
Vaccine exemptions are an illustration of the “tragedy of the commons,” in which parents choose not to vaccinate their children, relying on the fact that other parents will vaccinate their children, thus providing community immunity. However, the net result of many individual decisions not to vaccinate is the collapse of herd immunity and thus an upsurge in preventable disease and death.
The failure to vaccinate puts others at risk, thus violating an important ethical principle. However, punishing individual parents could entrench political opposition to vaccine policy. The most ethical and effective solution is for state legislatures to tighten vaccination laws, making it more difficult to obtain non-medical exemptions.
Unvaccinated patients pose a ‘clear and present danger’
But doctors also have some role to play in the effort to prevent people from skipping out on crucial recommended shots. Considering the fact that waiting rooms are particularly high-risk environments for disease transmission, especially for highly contagious diseases like measles, some doctors have started refusing to accept anti-vaccine patients into their practice.
“We decided that the patients who are not vaccinated are presenting a clear and present danger,” explained Dr. Charles Goodman, an LA-area pediatrician who recently implemented a mandatory vaccine policy after more than 20 years of practicing medicine without one. “It just wasn’t fair for a small number of patients to put those many patients, who either couldn’t be vaccinated because they’re too young or had a weakened immune system, at risk.”
The decision to turn away vaccine-refusing patents is not without controversy. The American Academy of Pediatrics states, “In general, pediatricians should avoid discharging a patient from their practices solely because a parent refuses immunizations for the child.” But that position statement, which has not been updated in a decade, may reflect a dated perspective that failed to take into account how prevalent vaccine-refusal would become, and a growing number of pediatricians are speaking out in favor of the opposite position, saying that they need to protect their patients.
As Dr. Eric Bell, a pediatrician in Southern California, told NPR earlier this month, “I have several patients a day who have threatened to leave our practice if we are still going to see patients that are unvaccinated. They do not want to see patients with measles or whooping cough in our waiting room for fear their baby might get sick from it.”
Sending the right message
According to Hart’s findings, of the pediatricians who require that patients vaccinate, 98 percent specifically necessitate the MMR inoculation that protects against measles.
Hart also found that, among the practices that made the switch to a vaccine requirement, 58 percent lost a few patients. But 61 percent of practices received a positive reaction from the patients who remained, while only 2 percent noted a negative reaction.
Perhaps the most provocative finding involves parents’ response to doctors taking a stand. Of the practices that switched to a vaccine requirement, 68 percent reported that some new families opted to comply, and 17 percent answered that many new families permitted their children be vaccinated. Hart said this finding underscores the positive impact that such policies can have, saying that doctors who take a stand on the matter are demonstrating its importance to patients. On the other hand, doctors who don’t require their patients to be immunized could unwittingly send the message that vaccinations are not that important.
“If we allow parents to be in our practice who don’t vaccinate their kids, we’re passively telling them that it’s OK,” said California-based pediatrician Dr. Eric Ball. “It’s not OK for those families, the community and for other patients.”
In an interview with CBS last month, Dr. Margaret Van Blerk, a pediatrician in Orange County, California, expressed the frustration that often results when patients are given the option to opt out of vaccines. “It’s just frustrating that they don’t listen,” she lamented, “because they come to us to take care of their children, and yet they don’t trust us.”
Although some doctors argue against turning away unvaccinated patients in favor of trying to educate parents about why they should vaccinate (with the eventual goal of convincing them to do so), research shows that efforts to change minds with evidence alone can backfire. A study published last year in the journal Pediatrics tested four different approaches: a leaflet debunking the vaccine-autism link; a leaflet about the dangers of the diseases that the vaccine prevents; images of children who have those diseases; and a mother’s narrative recounting her infant son’s hospitalization with measles. To the researchers’ surprise, none of these measures changed parents’ decision to forgo vaccination, and in some cases, the interventions strengthened parents’ determination not to vaccinate.
Most physicians who mandate vaccination say they try to work with patients before dismissing them from the practice, giving them a month or so to consider immunization or find another doctor. “We really don’t want to abandon them,” said Dr. Goodman. We have no ill will against them.” But for some patients, he said, there is simply no other choice: “No amount of reason, argument, science or logic, no amount of that will change the minds of these staunch anti-vaxxers.”
“I would encourage other pediatricians as well as family practitioners that treat children to do the same thing,” added Dr. Goodman. “Put your foot down now; tell those kids they need to get the immunizations.”