News & Views: A Different Approach to Vaccine Refusal Results in a Change of Heart — One Doctor’s Experience
Published on in Vaccine Update for Healthcare Providers
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Published on in Vaccine Update for Healthcare Providers
Editor’s Note: This month’s article was guest authored by Margaret Stager, MD, Director of the Division of Adolescent Medicine at MetroHealth in Ohio. We would like to thank her for sharing her experience and hope you find the article to be helpful in your approach to vaccine-resistant parents.
The first patient on my schedule was a 16-year-old boy whom I had never seen before. I reviewed the chart before I went into the room to inform myself about the patient’s health and psychosocial history. For this particular patient, I was alerted to a progress note from his previous pediatrician, who wrote a note following a recent well-child visit, “MOM REFUSED ALL VACCINATIONS – AGAIN.”
The pediatrician documented the vaccine education he provided, the time he spent discussing it with the mother, and a notation of “vaccine refusal” on the boy’s problem list. (Of note, mom was single and father was not involved in his son's care.) The boy had received some vaccines and had not suffered any documented reactions. I took a deep breath and sighed. What could I possibly say to this mother knowing that the previous pediatrician, who is an excellent communicator and educator, couldn’t convince her of the benefits of vaccines?
As I entered the room, I decided to stay as neutral as possible, opening the visit with a general introduction of myself and the adolescent medicine clinic. Within minutes, she interrupted me, waved her hands through the air, and proclaimed in a definitive voice, “Just so you know, I don’t believe in vaccines. I think they are harmful, and I’m against them. Just ask Dr. B., his previous doctor. He knows how I feel about this.” I affirmed her position and explained that we would save the vaccine discussion for the end of the appointment. She told me, “We don’t need to talk about vaccines. I’ve already had many conversations with Dr. B. about it,” waving me away with a curt smile.
As is the standard of care in adolescent medicine, mom agreed to leave the room while I met privately with her son. He was a healthy, smart, athletic, introverted boy, who in a few months would be going away to boarding school for the first time, about 10 hours away. He was, understandably, apprehensive about the new school and living so far away from home. I counseled him about what life might be like at boarding school, having a roommate, and other topics that would be pertinent to his new experience.
When mom returned to the room, I summarized the visit and reviewed the vaccinations that are recommended for adolescents, including Tdap, meningococcus and HPV. He was actually due for several more vaccines, such as the MMR, due to non-completion of the childhood vaccination schedule, but I focused on the adolescent ones for the moment. Again, mom refused, but this time with even more anger and insistence. The boy said nothing and shrugged his shoulders. It was clear he didn’t want to get involved in the conversation, despite my asking him his position about vaccines.
I realized that directing my education toward the mom would only be met with hostility and rebuttal. So, I decided to take another approach. I turned my chair away from the mother and focused my full attention on the boy. I explained to him that since he wouldn’t be receiving the vaccines I had mentioned, he wouldn’t be protected against those diseases. I told him I wanted to take a few minutes to explain exactly what the diseases are like when they begin, so that should he get sick with a vaccine-preventable disease at school, he would be prepared to recognize the early symptoms and seek medical care.
First, I acknowledged that it is difficult to predict whether he would become ill with any of these diseases, but added that it was better to be prepared should it happen. Next, I pointed out that some of his classmates could be international students, coming from countries where diseases, such as polio, measles or hepatitis, may be prevalent, and, therefore, his chance for exposure could be greater.
Next, I spent several minutes describing the swollen painful glands (and testicles) of mumps, the rigid, life-threatening spasticity of tetanus, the three-month cough and post-tussive emesis of pertussis, the jaundice and malaise of hepatitis, the potential paralysis of polio, the genital warts and potential cancers of HPV, and the rapid onset of fever, neck stiffness, headache and risk of death from meningitis. Both the boy and mother sat in stillness, listening with rapt attention. The boy looked especially vulnerable.
When I finished, I asked if they had any questions about the diseases. At which point, the mom asked, “Would you give these vaccines to your children?” I quickly told her I had already because I wanted them protected from these awful diseases that could make them very, very sick or kill them. The mother took a deep breath and responded, “OK. I’ll agree to him getting the vaccines. I don’t want anything to happen to him while he is away at boarding school.”
I considered this a major victory, albeit one single case. Nonetheless, I realized that a novel approach to a vaccine-resistant parent may be to not flood them with more safety and efficacy data, but rather to describe, in detail the diseases themselves.
In this era of generations removed from polio, H. Influenzae, diphtheria, tetanus, etc., we have a collective loss of the knowledge and experiences with vaccine-preventable diseases. Today’s parents, and even some young healthcare providers, do not know what it was like to have these diseases. Therefore, we may need to review the basics of diseases with parents. What does the disease “look” like? How does it affect a child? What complications may occur? For some, vaccine-preventable diseases are nothing more than words on a page describing an abstract illness that they can’t imagine and don’t perceive as life-threatening.
Creative point of care strategies are increasingly needed for healthcare providers on the frontlines, so together we can improve vaccination rates, maintain or increase herd immunity, and keep our communities healthy. Educating those who are considering abstaining about “how they should be prepared” is a potentially impactful counseling tool.
Contributed by: Charlotte A. Moser, MS, Paul A. Offit, MD
Categories: Vaccine Update June 2019, News and Views About Vaccines
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