Research has shown that children who are exempted from vaccinations have a 35-fold higher risk for measles, a 23-fold higher risk for pertussis and a nine-fold higher risk for varicella than do vaccinated children.
Citing these and similar statistics, the Pediatric Infectious Diseases Society, or PIDS, recently released a position statement(www.pids.org) opposing any legislation or regulation that would allow children to be exempted from mandatory immunizations based on their parents' -- or, in the case of teens, their own -- secular personal beliefs.
"More personal exemptions mean more children who aren't vaccinated," said Paul Hunter, M.D., associate medical director for the City of Milwaukee Health Department and one of three former AAFP vaccine science fellows who recently talked to AAFP News Now about immunization policies. "You have to have a high percentage of children vaccinated to have herd immunity and prevent disease spread. If you get clusters of people in a community using personal exemptions, that's when outbreaks happen. That particular community is going to be at risk."
Add one more group to the growing list of health care organizations calling for mandatory annual influenza vaccinations for health care personnel. The American Medical Directors Association, or AMDA, recently released a position statement(www.amda.com) supporting mandatory vaccination for health care personnel with direct patient contact in long-term care.
The AMDA joins the following groups with similar positions:
- American Academy of Pediatrics;
- American College of Physicians, or ACP;
- American Public Health Association;
- Association for Professionals in Infection Control and Epidemiology;
- Infectious Diseases Society of America;
- National Foundation for Infectious Diseases;
- National Patient Safety Foundation; and
- Society for Healthcare Epidemiology of America.
Although the CDC's Advisory Committee on Immunization Practices, the American College of Obstetricians and Gynecologists, the ACP and the AAFP have recommended(4 page PDF) for years that all health care workers receive annual influenza immunizations, less than half of health care workers are immunized against the flu each year(www.nfid.org), according to the CDC.
Currently, the AAFP's Commission on Health of the Public and Science is reviewing a policy on mandatory influenza vaccinations for health care personnel.
Such policies can be difficult to enforce, however. In 2009, the New York state health commissioner announced that vaccination against the seasonal flu and novel influenza A (H1N1) would be required for all health care personnel, but the regulation was suspended amid protests from nurses and public health workers, as well as because initial supplies of H1N1 vaccine were limited.
Jamie Loehr, M.D., a former AAFP vaccine science fellow from Ithaca, N.Y., said mandatory flu vaccine is "a perfectly legitimate public health requirement."
"We are already required to be immune to measles, mumps and rubella before working in the hospital and need annual tuberculosis testing," he told AAFP News Now. "This requirement is merely an extension of those precedents."
Everett Schlam, M.D., another former vaccine science fellow and assistant director of Mountainside Family Practice Associates in Verona, N.J., said his practice requires workers to wear a mask and sign a declination statement if they are not vaccinated against the flu.
Finally, says the statement, some states allow an exemption to be made based on parents' personal secular beliefs.
As the PIDS statement observes, however, states do not allow religious or personal belief exemptions in other instances meant to safeguard children's health, such as requiring them to ride in car seats until they reach a certain age and weight threshold. "In this context, it is wrong to allow parents to exempt their children from required immunizations based on their personal beliefs," says the statement.
With this in mind, the statement calls for any legislation or regulation regarding personal belief exemptions to contain the following provisions to minimize use of exemptions:
- The personal belief against immunization must be sincere and firmly held.
- Before a child is granted an exemption, the parents or guardians must receive state-approved counseling on the importance of immunization, vaccine safety, and the consequences of exemption for their child, as well as for other children in the community who are vulnerable to disease and cannot otherwise be protected.
- Before a child is granted an exemption, the parents or guardians must sign a statement that delineates the basis, strength, and duration of their belief; their understanding of the risks that refusal to immunize has on their child's health and the health of others; and their acknowledgement that they are making the decision not to vaccinate on behalf of their child.
- Parents and guardians who claim exemptions should be required to revisit the decision annually with a state-approved counselor and should be required to sign a statement each year to renew the exemption.
- Children should be barred from school attendance and other group activities if there is an outbreak of a disease that is preventable by a vaccination from which they have been exempted. Parents and guardians who claim exemptions for their children should acknowledge in writing their understanding that this will occur.
- States that adopt provisions for personal belief exemptions should track exemption rates and periodically reassess the impact that exemptions may have on disease rates.
Vaccine science fellow Jamie Loehr, M.D., said 20 percent of families in his practice in Ithaca, N.Y., refuse all vaccines, and 30 percent use a delayed vaccination schedule. Loehr said he tries to overcome vaccine resistance with education, and some parents who had refused to vaccinate their children in the past now are starting to accept immunizations.
"I tell them that if they are coming to me, they have to politely listen to me advocate for vaccines with each well-child visit, even if they know they are going to refuse vaccines," Loehr said. "At the visits, I share stories of vaccine illnesses that have affected children in the U.S., I discuss vaccine success stories, and I refute any misinformation they have about vaccines."
Last year, the CDC, in collaboration with the AAFP and the American Academy of Pediatrics, released free resources(www.cdc.gov) to help physicians talk with parents about vaccinating their children. The materials include information for parents about vaccine safety, the diseases that vaccines prevent and the risks associated with not vaccinating.
According to Everett Schlam, M.D., assistant director of Mountainside Family Practice Associates in Verona, N.J., and a 2009-10 vaccine science fellow, listening to parents' concerns about vaccines is an important part of getting them to listen to the physician's perspective.
"A significant percentage of parents can be persuaded if you understand their point of view," he told AAFP News Now. "I find out why they're resistant. Then I validate that reason: 'I understand why you feel that way.' Then I go through the evidence-based information and give them a strong recommendation: 'I receive the vaccine myself and recommend it for my family members. It's an important health care strategy.' It's education. It does take time, but I've found it successful."