1. health and fitness
2. disease
3. cold and flu

Focus on CME at
Dalhousie University
How to Manage
Parents Unsure
About Immunization
With the emergence of anti-immunization groups, more parents are opting
not to inoculate their children. While physicians must listen to the arguments
presented, it is their responsibility to educate parents on the importance of
immunization.
By Scott A. Halperin, MD
Presented at Dalhousie University, Day of Pediatrics, Truro, Nova Scotia, April, 1999.
I
mmunization programs throughout the developed world increasingly are becoming victims
of their own success. High levels of childhood
immunization coverage and global-targeted efforts
have eradicated smallpox, eliminated polio from
the western hemisphere and made remarkable
gains in the global effort to eradicate polio. The
rate of measles has diminished in most of the
Americas, and Haemophilus influenzae (H. Flu)
type b meningitis has been nearly eliminated in
Dr. Halperin is professor of
pediatrics and associate
professor of microbiology and
immunology, Clinical Trials
Research Centre, Dalhousie
University, and the Izaak Walton
Killam Grace Health Centre,
Halifax, Nova Scotia.
62 The Canadian Journal of CME / January 2000
Canada and the United States. With the disappearance of these once common and deadly diseases,
many young adults of child-bearing age no longer
have first-hand experience of these illnesses, and,
therefore, have not learned to fear them.
Concurrent with this epidemiological and intellectual lack of exposure to these vaccine-preventable diseases, a vocal anti-immunization
movement has grown, and it has become increasingly sophisticated and subtle. Often, these organizations had their beginnings in a personal
tragedy in which the founder, or his/her child,
developed a condition that the individual attributed to receiving a vaccine.
Unfortunately, the medical community often
inadvertently plays a role in this process through
misinformation, or inadequate communication and
understanding. As these organizations have
matured, many no longer claim to be anti-immunization, but, instead, promote themselves as pro-
Case Study
A young couple enters your office with
their two-month-old child. They indicate
that they are unsure whether or not they
should begin the infant immunization
series. They would like to discuss the
issue with you.
Sitting in your office, the parents say
that the diseases against which the
vaccine protects no longer exist, and
that no one they know ever had any of
these illnesses. They go on to say that
they have heard the vaccines are more
dangerous than the diseases are, and,
besides, with so many other children
immunized, their child will be safe, even
if left unimmunized. Finally, they express
the concern that the immune system is
being overwhelmed, and suggest that it
might be better to let their child have the
diseases, one at a time. You settle back to have an open and frank discussion about
immunization with the parents.
informed choice. Advances in electronic communication and publishing technology facilitate dissemination of information in highly professional
formats.
Parents are confused because they are inundated with information and have no means to “separate the wheat from the chaff.” The popular
media, citing principles of equal time and treatment, present both sides of the immunization issue
as if the arguments have equal scientific validity.
Parents, such as the ones mentioned in the Case
Study above, continue to turn to their family physician for advice. The following is an eight-step
approach to addressing the issues raised (Table 1).
Listen, Evaluate, Categorize
One of the most effective interventions with parents is to be a good listener. Determine the specific concerns of the particular parents so that they
know you are taking their concerns seriously. This
will strengthen the patient-physician bond and will
facilitate the informed decision-making process
that you hope will take place. It also assists you in
tailoring the selection of information, reasons and
arguments most likely to be effective. Inherent in
being a good listener is having sufficient time to
listen, without the pressures of a next appointment. Therefore, be aware that effective management of these issues cannot be done in a short
The Canadian Journal of CME / January 2000 63
Immunization
Table 1
Eight-Step Approach to Respond to
Parents Unsure About Immunization
1.
Listen, Evaluate, and Categorize
2.
Recognize Legitimate Concerns
3.
Provide Context
4.
Refute Misinformation
5.
Provide Valid Information
6.
Recognize That it is the Parents’
Decision
7.
Educate About Potential Consequences
8.
Make a Clear Recommendation
visit, but requires a prolonged (45- to 60-minute)
counseling session.
Evaluating and categorizing your audience may
seem cynical, but it may permit you to spend time
more effectively with parents who truly seek
advice, and to avoid the frustrations and wasted
effort with those who do not. In the author’s practice, he has divided parents referred to him into
five separate categories:
Uninformed but Educable. These typically are
parents who have been told by friends or relatives
that they should not immunize their infant, but do not
yet hold those views themselves. They are looking
for information and often are seeking help in countering the arguments of those giving them contrary
advice. The chance of achieving a positive outcome
(immunization) for infants of these parents is high.
Misinformed but Correctable. Parents in this
group have more information than the preceding
64 The Canadian Journal of CME / January 2000
group, often obtained from a television or radio
talk show, a parenting magazine, or the Internet.
They typically have not been presented with the
“other side of the story” and often are unaware
that there is a counter argument. Although occasionally resistant to giving up these new-found
beliefs (the first information learned about an
issue is often the best-learned), they slowly may
moderate their position, and frequently consent to
immunization—if not that day, then at a later visit.
Well-Read and Open-Minded. These parents
typically have been exposed to the anti-vaccination information, but have explored the issues
more thoroughly through additional reading. They
come to you for further discussion and for assistance in putting the proper weight on each argument. They appreciate your assistance in pointing
out the fallacies or false logic of many of the statements and “facts” they have read, particularly on
certain Internet Web sites. One needs to be well
prepared for discussions with these parents,
although, ultimately they will agree to immunization. Interestingly, these parents often provide
phased agreement to immunization (i.e., they first
consent to immunize with certain antigens and,
over time, agree to the use of others).
Convinced and Content. Parents in this category are convinced that immunization is bad for their
children and are content with their decision. The
only reason they find themselves in your office is
to please someone else, such as their parents, who
have badgered them to at least discuss the issue
with their physician. As a pediatric infectious disease consultant, the author often is referred parents in this category, who agree to the referral so
as not to jeopardize their relationship with their
family physician. Success is unusual, and the most
one can hope for is to plant a seed of doubt that
may lead them to re-examine their position in the
future. Extensive discussion with this group of
parents is seldom productive.
Committed and Missionary. These parents are
typically “card-carrying” members of the anti-vaccination movement and come to your office, not to
discuss the role of immunization, but rather to
convince you that immunization is evil and that
you should no longer immunize any of the children in your practice. A good clue that parents are
in this group is that they rarely bring their children
to the office visit. Parents in this category probably will cling to their beliefs and not appreciate the
value of immunization; therefore, extensive discussion is non-productive.
Recognize Legitimate
Concerns
In discussing immunization, it is essential that
health-care providers recognize that adverse events
are associated with vaccines and the parents concerns are legitimate. Physicians should emphasize
that most adverse events are mild and self-limited—
such as fever, soreness at the injection site and irritability. Physicians also should discuss less common, more severe adverse events, stressing that
most have no lasting effect. An example of this type
of event is a febrile seizure. Finally, one should not
deny or ignore real, but rare, severe adverse events
that can be caused by immunization, such as anaphylaxis with any vaccine, vaccine-associated paralytic polio from oral poliovirus vaccine, and disseminated bacille Calmette-Guérin (BCG) infection.
Provide Context
Context is important when discussing risk with
parents. Risk often is misunderstood and perceived
as an all-or-nothing issue. It is useful to provide
parents with the comparative risks associated with
the vaccine and with the disease, and to discuss the
likelihood of becoming infected in the absence of
immunization. A good example is febrile seizures,
Immunization has been one of the major
medical advances and has saved
countless lives over the past 50 years.
which occur after one in 1,700 doses of the wholecell pertussis vaccine and twentyfold more frequently after natural infection.
It is also important to let parents know what
has happened in countries where immunization
rates have fallen, and where the vaccinepreventable disease re-emerged. Describe the
experience in the United Kingdom, Sweden and
Japan, after their pertussis immunization programs were disrupted, where the number of
adverse events associated with the resurgence of
pertussis dwarfed the adverse events previously
associated with the vaccine.
The Canadian Journal of CME / January 2000 65
Immunization
Rare vaccine-associated adverse events also can
be placed into context with natural-occurring
adverse events. For example, the estimated risk of
encephalopathy after measles vaccine is one per
one million to two million doses. Given that nearly
eight million doses of measles vaccine are administered in the United States annually (twice the birth
cohort in their two-dose measles program), one
would expect to see several cases of encephalopathy per year. This risk is similar to that of dying
from being struck by lightning or a tornado.
Parents often are concerned about the
risk they take by immunizing their child,
but ignore risks taken by not immunizing.
Refute Misinformation
Do not allow yourself to be surprised by the antivaccination groups. Know their current claims and
be able to demonstrate their fallacies. There are
many sources of misinformation, including television “documentaries,” magazines, newspapers,
and most effectively, the Internet. Visit the antivaccination Web sites and examine their tactics.
Spend time exploring their links so you are familiar with the type of information to which the
child’s parents are exposed. These sites are well
established, glossy, and are updated frequently, so
return visits are advisable. Some Web sites in this
category worthy of exploration include:
• “The National Vaccine Information Center”
(www.909shot.com);
• “Vaccines: The Truth Revealed”
(www.odomnet.com/vaccines/); and
• “People Advocating Vaccine Education
(www.vaccines.bizland.com/)
68 The Canadian Journal of CME / January 2000
Recognize, however, that it is not realistic to expect
to keep abreast of every new adverse event that
some group contends is caused by immunization.
When confronted by a parent with a new concern,
avoid using the response: “Well, I guess it’s possible,” because that may be all the parent takes away
from the conversation. Instead, tell the parent honestly that you have not heard about that alleged association, but will obtain more information for them.
Contact Health Canada or the Centers for Disease
Control (see next section), who continuously update
information about vaccine-associated adverse
events and vaccine-adverse event allegations.
The following lists a few examples of common
misconceptions, and possible physician responses
to the questions raised:
1. Patient: “Before vaccines were introduced,
these diseases already had begun to disappear
because of better hygiene and sanitation.”
Physician: “The recent success with H. Flu type
b-conjugate vaccines have virtually eliminated
meningitis due to this pathogen at a time when
there has been no change in hygiene or sanitation in North America.”
2. Patient: “The majority of people who get the
disease have been vaccinated.”
Physician: “As immunization rates rise, an
increasing number of cases that occur will be
vaccine failures since no vaccine is 100% effective; however, the total number of cases occurring has diminished dramatically.”
3. Patient: “There are problems with the vaccines
that we don’t yet know.”
Physician: “Long-term safety monitoring has
yet to identify such problems.”
4. Patient: “Vaccine-preventable diseases have
now been eliminated from North America, so
we can stop immunizing.”
Physician: “The resurgence of pertussis and of
diphtheria in the countries of the former Soviet
Union where vaccination was discontinued
Immunization
provides a dramatic demon- • Your Child’s Best Shot, written
stration of the fallacy of this
by Dr. Ronald Gold, and pubargument.”
lished by the Canadian
5. Patient: “Giving a child multiPaediatric Society in 1997 (in
ple vaccinations for different
English and in French); and
diseases at the same time • What Every Parent Should
increases the risk of harmful
Know About Vaccines, by Dr.
side effects and can overload
Paul Offitt, and published by
the immune system.”
MacMillan in 1998.
Physician: “Adverse events
There are excellent Internet
associated with combination sites with immunization inforvaccines are usually less than mation directed toward parents,
the total effect
including:
of the diseases
• The Canadian
involved. The
Paediatric
immune sysS o c i e t y
he immune system is
tem is exposed
(www.cps.ca);
exposed to far more
to far more
• H e a l t h
antigens every day
antigens every
Canada’s
from
breathing
and
day
from
Immunization
breathing and eating than could ever
Division
eating
than
(www.hc-sc.gc.
be provided in an
could ever be
ca/hpb/lcdc/
immunization.
provided in an
bid/di/index.html);
immunization.”
• The National
Immunization Program of the
USA Centers for Disease
Control (www.cdc.gov/nip);
Provide Valid
• The National Immunization
Information
Information Network of the
Do not be defensive. Respond to
Infectious Disease Society of
the misinformation, but also proAmerica and the Pediatric
vide additional, more reliable
Infectious Diseases Society
data, including information on the
(www.idsociety.org/vaccine/
eradication and elimination of disindex.html);
eases, decreases in infant mortali- • The Department of Vaccines
ty, and the effects of interruptions
and
Biologicals
in vaccine programs. Provide
(www.who.ch/ gpv-safety);
information in understandable for- • The Institute for Vaccine Safety
mats. References directed to parof Johns Hopkins University
ents should include:
(www.vaccinesafety.edu); and
T
The Canadian Journal of CME / January 2000 73
Immunization
• The
Immunization
(www.immunize.org).
Action
Coalition
Recognize That It Is the
Parents’ Decision
Immunization is not compulsory in Canada. Two
provinces, New Brunswick and Ontario, have
school-entry requirements, but parents can opt not
to have their child immunized. The goal is to convince parents to immunize their children by the
overwhelming logic of the argument, but you will
not always be successful.
Educate About Potential
Consequences
Be sure that parents understand the consequences of
their children contracting the disease in question, and
that they are placing their child at risk. Challenge
them to ask themselves what their children would
want them to do if they could express an opinion.
Parents often are concerned about the risk they
take by immunizing their children, but ignore risks
taken by not immunizing them. It seems that concern
about the guilt associated from risks of commission
(vaccinating) is greater than concern about the guilt
associated with the risks of omission (not vaccinating). This myth must be dispelled and parents must
be helped to realize that there should be no guilt associated with a well-thought-out decision to minimize
the risks to their children by immunizing them.
Make a Clear
Recommendation
Avoid being direct unless specifically asked, but
leave no doubt as to your opinion and recommendation. If you are unsure, the parents will be as
well. Parents consistently indicate that the physician’s advice about immunization is the most
74 The Canadian Journal of CME / January 2000
important factor in their decision-making process.
Therefore, do not be subtle or indecisive.
Summary and Conclusion
Immunization has been one of the major medical
advances and has saved countless lives, over the
past 50 years. It remains one of the most costeffective medical interventions available.
Increasing unfamiliarity with vaccine-preventable diseases, underestimation of the disproportionate influence of the small, but vocal, anti-vaccination movement, and complacency amongst
health-care providers about the public’s vulnerability to well-packaged misinformation may place
the hard-fought advances in prevention of infectious diseases in jeopardy.
Given appropriate information and resources, the
primary-care physician is best suited to promote the
goals and benefits of a well-immunized population.
Acknowledgments
Thank you to Dr. Robert Pless for reviewing the
manuscript and providing helpful thoughts and
comments.
Suggested Reading
1. Ball LK, Evans G, Bostrom A: Risky business: challenges in
vaccine risk communication. Pediatrics 1998; 101:453-8.
2. Gold, R: Your Child’s Best Shot: A Parent’s Guide to
Vaccination. Ottawa: Canadian Paediatric Society; 1997.
3. Offit, PA, Bell LM (eds.): What Every Parent Should Know
About Vaccines. MacMillan, New York, 1998.
4. Pless R: Vaccine safety resource material for providers and
the public. Can Commun Dis Rep. 1998; 24:141-4.
5. Stanwick R: Immunization information on the web site—
A risky business or misconstrued risk? Pediatr Child Health
1998; 3:311-2.
6. Stratton KR, Howe CJ, Johnson RB (eds.): Adverse Effects
of Pertussis and Rubella Vaccines. National Academy Press,
Washington DC, 1991.
7. Stratton KR, Howe CJ, Johnston RB (eds.): Adverse Events
Associated with Childhood Vaccines: Evidence Bearing on
Causality. National Academy Press, Washington DC, 1994.
Information for Patients
Immunization
Resources for Parents
Immunization is an important preventative health
care measure that you can provide for your children. Many parents are concerned that vaccines
may be harmful because of things they have heard
from friends, read in newspapers or magazines,
heard on the radio or television, or found on the
Internet. The following list of books and Internet
Web sites contain information that is useful and
dependable, and will help you make the best decision for your children’s future.
Books
• Your Child’s Best Shot: A Parent’s Guide to
Vaccination, written by Dr. Ronald Gold and
published by the Canadian Paediatric Society,
1997. Available in English and French; and
• What Every Parent Should Know About
Vaccines, by Dr. Paul Offitt, and published by
MacMillan, 1998.
Internet Web Sites
• The Canadian Immunization Awareness
Program (www.ciap.cpha.ca)
• The Canadian Paediatric Society (www.cps.ca)
• Health Canada’s Immunization Division
(www.hc-sc.gc.ca/hpb/lcdc/bid/di)
• The National Immunization Information
Network of the Infectious Disease Society of
America and the Pediatric Infectious Disease
Society (www.idsociety.org/vaccine/index.html)
• The Department of Vaccines and Biological
(www.who.int/vaccines-diseases/)
• The Institute for Vaccine Safety of Johns
Hopkins University (www.vaccinesafety.edu)
and
• The Immunization Action Coalition
(www.immunize.org)
Other Instructions
Prepared by Dr. Scott A. Halperin, professor of pediatrics
and associate professor of microbiology and immunology, Clinical Trials Research Centre, Dalhouse University,
and the Izaak Walton Killam Grace Health Centre, Halifax,
Nova Scotia.
May be copied and distributed to patients.
The Canadian Journal of CME / January 2000 75