Amid a resurgence of measles across the country, many physicians aren’t sure how to talk with patients whose confidence in vaccines has wavered as a result of the anti-vaccination movement.
Today, patients’ concerns about vaccinations fall along a spectrum, with some refusing all vaccines while others are more hesitant about specific immunizations like the MMR vaccine or receiving several vaccines at once.
As vaccines have eradicated illnesses, some patients no longer view these diseases as threats. They may believe that real or perceived adverse events from vaccinations are a bigger threat than the illnesses themselves, says Saad Omer, MBBS, MPH, Ph.D., director of the Yale Institute for Global Health in New Haven, Conn., and a vaccination researcher.
Mistrust of government, drug companies, and healthcare providers as well as misinformation about vaccines spread by anti-vaccine advocates are also factors fueling vaccine hesitancy. Along with access and insurance issues, they could be contributing to a downward trend in vaccination rates.
CDC data show the percentage of unvaccinated children is rising, with 1.3 percent of children born in 2015 not receiving any recommended vaccinations, compared with 0.9 percent of children born in 2011.
Facing increased reluctance
Douglas DeLong, MD, FACP, chair of ACP’s Board of Regents and chief of general internal medicine at Bassett Medical Center in Cooperstown, N.Y., says his general internal medicine practice has not been affected by the anti-vaccination trend to the extent that many pediatric or family medicine practices have.
Still, he has sensed increasing reluctance among some of his patients to receive immunizations, particularly the influenza vaccine, which some erroneously believe causes the flu.
Like many practices aiming to boost immunization rates, DeLong’s office sends patient reminders when vaccinations are due, as well as recall notices when patients are overdue for their shots. When he encounters a patient who is reluctant to receive an immunization, he tries to discuss the science behind vaccines but says this strategy often fails to change minds.
Emphasizing vaccination as the norm
So which techniques can improve physicians’ chances of getting their patients vaccinated? One is by making a presumptive statement that assumes the patient will be vaccinated.
For example, rather than asking parents if they are ready for their child to get a shot, a physician might say, ‘It’s time for Johnny to get vaccinated.’ Such an approach doesn’t take away the parents’ choice to say no, says Yale’s Omer. “What it is doing is framing it as a routine procedure, which it is, based on its safety profile.”
Some studies have shown this technique can improve vaccine uptake.
Of course, presumptive announcements are not a solution for every patient. “You won’t get absolute vaccine refusers with this approach, but you will get a lot of parents who are on the fence,” says Sean O’Leary, MD, associate professor of pediatrics and infectious diseases at the University of Colorado Anschutz Medical Campus in Aurora, Colo. “By taking that presumptive approach, you’re emphasizing vaccination as the social norm.”
Asking permission to share facts
If presumptive announcements fail, physicians can try motivational interviewing, in which they try to elicit the reasons why patients are refusing vaccines and then ask permission to share facts.
O’Leary explains how it works: The physician might ask an open-ended question such as, ‘What concerns do you have about the vaccine?’ After parents share why they are hesitant to vaccinate their child, the physician rephrases their concerns, then might say, ‘I’ve looked into this a great deal. Would it be OK with you if I shared what I’ve come to find out?’
“Simply asking that question makes people more receptive to the information that you are then going to impart,” O’Leary says.
In randomized trial results published in 2018 in JAMA Pediatrics, O’Leary and colleagues found that motivational interviewing helped improve HPV vaccine series initiation by 9.5 percent among parents who were resistant to vaccinating their teens.
Currently, O’Leary is collaborating on an NIH-funded study to investigate combining presumptive announcements and motivational interviewing to improve uptake of the infant series of vaccines.
O’Leary cautions that physicians should be careful when seeking to debunk vaccine myths because this strategy can backfire. In fact, talking too much about a myth can have the opposite effect of reinforcing the misinformation, experts say.
Yale’s Omer adds that when physicians want to counter a myth outright, they should be clear about labeling the myth as such. Then they can explain why it’s not true and offer an alternative explanation.
For example, if a parent believes that the MMR vaccine causes autism, the physician should say this is a myth. Then the physician can reference the wide body of evidence, mention that several genes have been linked to autism, and connect the increasing prevalence of autism to better diagnosis and monitoring of the disorder, Omer says.
Another strategy Omer suggests is for physicians to focus the discussion on the disease the vaccine prevents, not the vaccine itself. This helps build their credibility as disease experts. “If you’re talking about the disease, you’re on stronger ground than if you are going through the nitty-gritty of countering every myth,” he says.
Closing the doors to non-vaccinated patients
For practicality, patient safety or other reasons, some physicians are dismissing existing patients or refusing new ones if parents do not agree to follow the recommended vaccination schedule.
Paul Ehrmann, DO, medical director for the Family Health Care Center, a family practice in Royal Oak, Mich., is upfront with patients about maintaining a traditional immunization practice that requires full vaccinations. As such, the practice does not take new pediatric patients if their parents do not want them vaccinated.
Ehrmann estimates that he has declined fewer than a dozen patients. However, he has not dismissed the handful of patients in his practice who are not immunized and joined the practice more than 30 years ago when the practice did not have specific guidelines.
His practice’s website describes its vaccination philosophy, and office staff are trained to convey it respectfully and without judgment on the phone with prospective patients. “We try to set the tone before we see the patient,” Ehrmann says.
When talking with patients who have concerns about vaccinations, Ehrmann favors a low-key approach that focuses on the benefits of vaccinating based on the research. “I try not to be argumentative or contentious in any way,” he says. However, he wants to make sure that there is no misunderstanding his pro-vaccine position.
When asked, Ehrmann will sometimes stagger shots for children under age two whose parents are reluctant to have them receive several shots at one time. “I respect that and don’t push that, but I try to get the kids caught up as soon as we can,” he says.
In Oakland County, where Ehrmann practices, more than 40 cases of measles had been identified at press time, but none in his practice. Given the threat of future outbreaks, he believes physicians have a responsibility to do what they can to improve immunization rates.
“We respect patients’ feelings, however, we are stewards of not only our patients but also the public health and community at large,” he says.
Collaborating on solutions
Of course, physicians are not the only ones who can reverse the anti-vaccination trend, experts say. Employers could offer on-site flu shots. Payers could start reimbursing providers for vaccine counseling even when a vaccine is not administered. The federal government could withhold health or education funding to states that do not eliminate non-medical vaccine exemptions. Social media platforms could step up their efforts to curtail false information about vaccines.
Although coordinating such efforts will not be easy, Yale’s Omer is optimistic about the outlook in the United States compared with European countries such as Germany, France, Great Britain, and Italy that have had national outbreaks of measles. He credits school-entry vaccine requirements and public health agencies for maintaining immunization rates and quickly responding to measles outbreaks in the United States, as well as professional medical societies for their strong vaccine advocacy.
“There are a lot of things we don’t do well,” Omer says, “but this is one thing we do very well.”
Eliminating non-medical vaccine exemptions
In light of the recent measles outbreaks, it is likely that more states and localities will move to eliminate non-medical vaccination exemptions, says Lawrence Gostin, JD, professor and director of the O’Neill Institute for National and Global Health Law at Georgetown Law in Washington, D.C.
“The more measles is in the headlines, the more likely the government will be compelled to act,” says Gostin, who responded to questions via email. Oregon, for example, is considering eliminating non-medical exemptions, while cities such as Los Angeles and New York City now require vaccinations on university campuses and in Orthodox Jewish communities, he adds.
But state vaccination mandates will be ineffective if physicians fail to advise their patients to be vaccinated, actively discourage vaccination, or provide misleading information.
“After California eliminated non-medical exemptions, the number of medical exemptions went way up,” Gostin says. “Physicians are clearly not honestly filling in exemption forms and ignoring the overwhelming scientific consensus that vaccines are safe and effective.”
Federal policymakers are also stepping up efforts to combat the anti-vaccination movement. At press time, a bipartisan bill introduced by two physicians in the House of Representatives, Reps. Kim Schrier, MD, (D-Wash.) and Michael Burgess, MD, (R-Texas) would provide federal funding to monitor vaccine hesitancy and educate the public on vaccines. The bill is supported by American College of Physicians, the American Association of Family Physicians, the American Academy of Pediatrics, the American Osteopathic Association, and other groups.
“It is very important that we increase vaccination rates, because vaccines have been arguably the most important public health measure in modern medicine,” says Douglas DeLong, MD, FACP, chair of ACP’s Board of Regents and chief of general internal medicine at Bassett Medical Center in Cooperstown, N.Y. “It is important for us as physician-scientists to make that message loud and clear.”