How to answer difficult vaccine questions from parents

recent blog comes to the conclusion that non-vaccinating parents believe their pediatrician “would have to be staggeringly incompetent, negligent or malicious to keep administering (vaccines).”  Using this as the premise, this pediatrician goes on to say that these patients should be dismissed from our practices.

First off, these parents don’t think we’re the enemy.  The reason they bring their kids to see us is they trust us, they respect us and, most importantly, they want to do what’s right for their children. But when you search the Internet to find vaccine information and most of it is either boringly technical or rabidly anti-science, it’s hard to know where to turn.  ”Vaccines still prevent measles” is a boring story.  “Celebrity/talk show host/presidential candidate says vaccines cause horrible side effects” is misleading but gets hits.

Second, dismissing patients for making bad decisions is just plain wrong.  I have had plenty of families who have refused to try to quit smoking even when their child has spent days in an ICU with asthma.  Others stare at me in disbelief when I suggest that eliminating soda and chips will help their child lose weight and prevent imminent type 2 diabetes. But I don’t discharge them from my practice; I keep working with them. And the same thing must happen with vaccines refusers if we hope to make any progress at all.

The most successful technique is providing evidence-based reasons to vaccinate.  We need to reassure families that vaccines are safe and effective.  Our training and research tells us they are, but families don’t have our training.

We also need to emphasize that immunizing is what most families do.  Not immunizing is a big story and a big debate on the Internet, but in my practice, over 90 per cent of families fully vaccinated their children and know how important it is to protect them from these diseases.

Sharing stories of how and why people vaccinate is important. I used to have just my own story and those of my patients to use, but now there are myriad resources. Voices for VaccinesNurses Who VaccinateParents for VaccinesShot By ShotMoms Who Vaccinate, and dozens of Twitter feeds and blogs have started sharing stories as well.

The conversation with our patients who think they are not going to vaccinate needs to continue.  It can be frustrating, maddening even, but in the end it is very important and often satisfying.  We are not trained to do this well in medical school or residency.  I find that I need to make time, sit down, breathe deeply, and speak calmly, remembering that we all want what is best for the child.

After years of trial and error, I’ve adopted ways to engage in conversations with parents and patients that can help address fear and misinformation regarding vaccines.

Here are some of the ways I have started these conversations.

Parent: “So I keep hearing about the bad things vaccines do …”

Response: “Where did you hear them?

Parent: “Most of the things I’m hearing about tend to be from celebrities or on unreferenced opinion websites, and when I compare them to what scientific sources say, I get a very different picture.”

Response: ”Why don’t you give me some of your sources and I’ll give you mine and we can compare?”

Parent: ”I’m worried about autism.”

Response: “Of course you are.  I’m worried about autism, too. But the whole vaccines-autism connection has actually been a huge waste of energy and money that could have been better spent elsewhere.  It was a scare based on faked science.There are some great studies of ties between pesticides and autism, there are others showing connections between genetic disorders and autism.  But if we were going to look at what has been studied that doesn’t cause autism…vaccines have been proven not to be associated more than just about anything else.”

Parent: “I’m worried about additives.”

Response: “Me too. What additives are you worried about?  Some people are worried about thimerosal, but that has been removed from the equation. I know that some Internet sites talk about all sorts of ingredients that are in vaccines in microscopic amounts. And it’s great that these are being looked at, but the reality is science has shown us no adverse effects from additives in vaccines.”

Parent: ”I want to try an alternative vaccine schedule that I read about.”

Response: “While it may be better than nothing, an alternative schedule leaves kids open to infection.  Will you choose to leave them vulnerable to one form or meningitis but not another?  Are you going to risk the possibility of an outbreak of something we hadn’t planned for?  And, what about the trauma it will cause to ‘space out vaccines’ with a visit every few weeks for a shot compared to giving them together?”

Other conversations are to take advantage of opportunities to discuss vaccines.

Parent: “He fell into the side of the house and cut his face.”

Response: “I know you haven’t vaccinated before and have had some misgivings.  But now we’re faced with a difficult situation.  He really needs a tetanus shot to protect him.  As part of this shot, he’ll be getting the pertussis vaccine too, but since there have been a few pertussis outbreaks recently, I’m sure you can see why he needs that too. Let’s give it to him today.”

Parent: “I’ve been reading about this measles outbreak and I’m scared.”

Response: “I’m scared too and worried for your child. You’ve chosen not to vaccinate your child, and he is definitely at risk for measles now. There really is nothing else out there that is going to protect him.  It takes about two weeks to be protected, so let’s start today.”

Some of the best conversations I have had have really focused on why we vaccinate at all.

Even the most basic information to a doctor may be new information to a family.  I can’t count the number of terrified parents I’ve had in my office, thinking their children might have measles, not knowing that is part of what the MMR vaccine protects against.

Parent: “We breastfeed, eat organic and stay really active. We don’t need vaccines.”

Response: “Those are all great things.  They have all been shown to protect against many diseases, but none of them have been shown to protect against pneumococcus or rotavirus or any of the other diseases we vaccinate against. You’re already doing so much, let’s take that extra step and do the vaccines.”

Parent: “Do you really think he needs these vaccines?”

Response: “Yes, I do.  I have a son. I worry about his health, his development, what he eats, who he plays with.  I probably over-research everything.  And I vaccinated him. I also vaccinate myself to protect my health and my patients.”

Parent: ”But my kids are healthy.”

Response: “Yes, they are. And vaccines will keep them that way. Also, we need to think about other people.  Let’s say your child gets chicken pox. You’d keep him away from other people so they don’t get sick, but did you know the illness can be most contagious in the first few days as the rash shows up? In those few days, you could infect someone’s new baby or a person with cancer or a defective immune system. And while your kids might get away with a few scars from the pox, that other person could get really, really sick.”

Parent: “But nobody really gets these diseases any more.”

Response: “It sure seems that way some days.  But then we get an article about a measles outbreak, or a pertussis epidemic, and it reminds us that these diseases are under control, not gone. Personally, I can’t wait for the day for more of these diseases to be eliminated so we can stop vaccinating against them.”

Even with these conversations, there will be families who are in special circumstances.  I am still direct and use evidence-based arguments to vaccinate.

I had one parent who had multiple children with autism and others with chronic medical conditions. She was dismissed from another pediatrician’s practice for wanting to defer a round of vaccines. Our conversation went like this:

Parent: “I know vaccines didn’t cause my kids’ autism, but I notice that they regress for a while after shots. They also regress when they’re sick, so I’d like to do their shots slowly and when they’re not sick.

Response: “I haven’t seen anything in the literature about this sort of response to vaccines. I recommend that you fully vaccinate them now to protect them from these serious illnesses that could have severe consequences for the rest of the family. But I haven’t walked in your shoes. Tell me what you want to do.” (In this case, the kids were vaccinated, but late.  They did have some regression after some shots, but none after others. They also regressed periodically when they didn’t have shots.)

Another came to me with a chemistry degree and studies about immunoglobulin levels being protective after just a few shots.  We had to have a discussion about how long these levels stay high and how boosters provide lasting protection.  I pulled studies on one vs. two chicken pox shots. I discussed the impact of boosters on waning immunity levels.  And eventually the children were all immunized correctly.

Results will vary. Conversations will vary. But, as physicians, we have a duty to guide our patients to better health instead of shoving them out the door.

Andrew Cronyn is a pediatrician who blogs at Parents for Vaccinations.

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  • ninguem

    Why not add the fact that the person best known claiming the vaccines caused autism, was not just wrong, he was a fraud.

    http://en.wikipedia.org/wiki/Andrew_Wakefield

    Not just wrong. Not just mistaken.

    He was lying.

    http://www.cnn.com/2011/HEALTH/01/05/autism.vaccines/

  • Dr. Drake Ramoray

    Watch out for those patient satisfaction scores when talking about vaccines. /s

    • PedsDad

      When I was in a system that did scores, I was always in the top quintile (or some nonsense like that). My impression: patients always knew what to expect from me. I’m always honest, I’m willing to say when I don’t know something, and when I have a bad day I apologize for it. Vaccines really didn’t play into it.

  • goonerdoc

    That’s the thing though. You CAN NOT convince anti-vaxxers to vaccinate using science, logic, and evidence based reasoning. It does not work, period. Frankly, I don’t think there’s any way to do it, but that’s just my opinion

    • PedsDad

      My experience is that is true of a very small number of people, most of whom don’t go to doctors for routine matters any way (if there’s an emergency, they will change their minds pretty quickly and suddenly trust western medicine, but that’s another matter). Most people who are not planning to vaccinate their children will have been pressured by family and friends or gotten bad information from the internet or a celebrity. As they build a relationship with a physician and begin to trust us, science and evidence will usually help them decide to vaccinate.

  • FEDUP MD

    The difference between the nonvaccinating parent, and the examples you give of the smoking and soda/chip giving parents, is very different. The presence of the latter two children in your waiting room does not endanger other children directly. The wheezing asthmatic child does not give their wheezing to others, and the other kids are ‘t going to catch diabetes. These parents’ decisions are only directly affecting their own kids (yes, one could argue about indirectly affecting health costs, but it is not the same). However, if an unvaccinated child is in your waiting room, they can directly infect and injure the most vulnerable members of your practice. i have a two week old so I am very sensitive to this issue- all of her direct contacts are up to date on all shots including pertussis boosters. The decisions these parents make do not affect their kids alone.

    • PedsDad

      If your doctor is dismissing non-vaccinating patients, they may make their office ‘safer’ (and I’m sure they are also cleaning toys after every child touches them, terminal cleaning rooms with infectious disease patients in them, etc…) but they are making every other place (the grocery store, church, school) more dangerous. And where do you spend more time?
      The most common argument by doctors for dismissing these patients is not infection control, but that ‘if they won’t listen to me about vaccines, they won’t listen to me about anything else.’

      • FEDUP MD

        I spend much more time at the doctor’s office. As a pediatrician myself, I don’t take my kids anywhere in public with crowds until they are vaccinated, at least the first round. I can avoid the stores and church for a couple
        months, I can’t not take them to the doctor. I can control exposure as much as possible except for there.

  • PedsDad

    I’m sorry but I could only watch the first four minutes of Dr. Humphries and there were so many inaccuracies, I had to stop. Let’s look at a few of her statements…
    1. “if vaccines were so miraculous there would be lines around the block for them, but there aren’t” — My mother and many newspapers of the time will show you the lines people waited in for hours to get polio vaccines. And polio has been eliminated in most countries in the world because of this vaccine
    2. The old ‘doctors get rich off of vaccines’ — A recent study showed many private practices were considering dropping vaccines because of how much they are costing them. Most offices barely break even on vaccination.
    3. The ‘I’ve done the research and these other doctors haven’t’ line. Really?
    4. ‘People who get vaccines are the sickest people.’ I’d like to see the statistics on that. For many vaccines, the vast majority of people in the US are being immunized. Are they really getting sick?
    And, I’m sorry, but I couldn’t get the other link to work.
    I think it is easy to find a few people here and there who will say things like this. I’m not sure why. I don’t know why an internist with a subspecialty in nephrology would even think they were qualified to go against, not only all of us who actually work with vaccinated (and unvaccinated) kids every day but every major medical organization in the world. Watch a child die from whooping cough and suddenly pertussis vaccine makes sense. See an immune suppressed child try to fight horrible chicken pox infections they caught from an unimmunized child next door and you will understand the difference vaccination makes.

    • PedsDad

      I got the other link to work as well. The other doctor’s arguments don’t hold water either.
      Here’s what I’d say. If you’re going to get your car fixed, don’t go to an air conditioner rapairman. Similarly, if you have questions about vaccines, asking an infectious disease doctor if probably going to get you better information than asking a psychiatrist.

    • SteveMichaels

      Just taking your first example Doc, just because people lined up initially for the polio vaccine does not constitute proof of efficacy. At the same time that the vaccine was introduced, the actual definition of polio was changed. The newer, more stringent, definition meant that reported polio cases were going to drop significantly regardless of vaccination. Ask the Indian children who used to have between 3 and 8,000 cases of paralytic polio per year before the “eradication” and now have 47 to 60,000 cases of “non polio” acute flaccid paralysis which is better. Among the primary factors in vaccine “success” have been changed clinical diagnosis and renaming of diseases like polio being reclassified as “aseptic meningitis” or even Gullain Barre Syndrome.

      • PedsDad

        I wasn’t using the lining up for polio vaccine as proof of efficacy. It was a response to the nephrologist’s video in which she says that ‘if vaccines were so miraculous, people would be lining up for them.’