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This award-winning blog supplements the articles in Hospital Infection Control & Prevention.

In Many Pediatric Practices, Vaccination is an Offer You Can’t Refuse

By Gary Evans, Senior Writer, AHC Media

Parents, the next time you sit in a pediatric waiting room with your sick child surrounded by the symptomatic cacophony of similar pint-sized sufferers, you may wonder if your doctor is one of the 21% nationally who recently reported they no longer treat families that refuse vaccines for their children. You may find yourself hoping she is.

“The American Academy of Pediatrics discourages providers from dismissing families who refuse vaccines for their children, yet some providers continue to do so,” the authors of a new study note.1 “Some have hypothesized that dismissing families could lead to increased clustering of vaccine-refusing families within certain regions, leading to outbreaks of vaccine-preventable diseases. … Others have suggested that having a policy for dismissing families may actually increase vaccine uptake, as it provides a strong message to families on the importance of vaccination. Our findings could be consistent with this interpretation.”

Indeed, the researchers found that states that have a philosophical exemption law and an easy exemption process have lower vaccination rates and higher rates of vaccine-preventable diseases. They conducted a national representative survey and used multivariable analysis to assess factors associated with dismissal or retention of families that refuse vaccine. Overall, 83% of 534 responding physicians reported that in a typical month, 1% of parents refused one or more infant vaccines, and 20% reported that .5% of parents refused. Fifty-one percent reported they “always/often” require parents to sign a form if they refused.

In the finding of particular note, 21% of pediatricians but only 4% of family physicians reported that they “always/often” dismissed families if they refused one vaccine. Focusing on the pediatricians based on this finding, they found these dismissal doctors were more likely to be in private practice, from the South, and reside in a state without a philosophical exemption law to vaccination. In states in which philosophical exemptions are allowed, only 9% of pediatricians report dismissing families for refusing vaccines in the infant series of shots -- versus 34% in states that do not allow philosophical exemptions.

Vaccine refusal is a growing concern in the United States, the authors note. Recent outbreaks of vaccine-preventable diseases, such as measles and mumps, emphasize that even small proportions of parents refusing vaccines has important consequences. For example, in 2014, there were 23 outbreaks of measles in 27 states, resulting in the most measles cases in 20 years. In addition it was recently reported at the IDWeek conference in San Diego that some 9 million children and youth --1 in 8 of those age 17 and younger – are now susceptible to measles.2

“There are no known evidence-based strategies for face-to-face communication that are effective at convincing hesitant parents to receive recommended vaccines, even though pediatricians and family physicians report spending significant time attempting to do so,” the authors of the dismissal study report.

Thus, “firing” the patient, as some term it, appears to be the last resort, although many have argued against the practice on both ethical and practical grounds.

“We know little about the responses of families who have faced this decision, or about those who have actually been dismissed for refusing to vaccinate,” the authors conclude. “Given the frequency of this practice, this is clearly an area that deserves further exploration.”


1. O’Leary ST, Allison MA, MD, Fisher A, et al. Characteristics of Physicians Who Dismiss Families for Refusing Vaccines. Pediatrics 2015;136(6):1-10.

2. Bednarczyk R, Orenstein WA, Omer, S. Poster 1866. Estimating the Number of Measles-susceptible Children in the United States Using the NIS-Teen. Poster 1866. IDWeek. San Diego, CA. Oct. 7-11 2015

Gary Evans writes Hospital Infection Control & Prevention (HIC), Hospital Employee Health (HEH) and contributes to IRB Advisor (IRB). As Senior Writer at AHC Media, Evans has written numerous articles on infectious disease threats to both patients and healthcare workers, including pandemic influenza, MERS and Ebola. He has been honored for excellence in analytical reporting five times by the National Press Club in Washington, DC.