Over the past two decades, a combination of fraudulent scientific studies, irresponsible
reporting, and well-meaning but misinformed citizen activists has led to a steady
increase in the proportion of parents who have concerns about the recommended childhood
vaccine schedule. While overall vaccine uptake rates in the United States remain
high, these concerns have resulted in a significant expansion in the number of parents
who are delaying, and in extreme cases even refusing, vaccines for their children.
These actions have led to outbreaks of vaccine-preventable diseases: The largest
domestic measles outbreak of the past 15 years occurred in 2013, and 2011 and 2013
were the two years with the highest number of domestic measles infections since
the 1990s. All of the measles outbreaks in 2013 were caused by infections that originated
outside of the country—and the overwhelming majority of the secondary infections
occurred in deliberately unvaccinated children or infants too young to be vaccinated.
The human and economic costs of these outbreaks are worthy of attention; one recent
study estimated that the public sector cost of containing a single case
of measles is more than $10,000.22
As the scope of the problem has become more apparent, the public health and medical
communities have begun to examine the best ways to communicate with anxious or wary
parents. There has not, however, been a concerted effort to develop an evidenced-based
toolkit to guide these discussions. The following suggested areas of research would
provide the necessary data for such an effort.
CORE ISSUES AND RECOMMENDATIONS FOR RESEARCH
1. Parental Attitudes and Knowledge
- When and how are attitudes and beliefs about immunization formed?
- How do parents learn about vaccines? Where do they encounter vaccine information,
and how are they influenced by messages from expert and non-expert sources?
- How does the perception of the benefits to the individual versus the community shape
a parent’s decision to vaccinate his or her child?
- To what extent does vaccine hesitancy result from a broader distrust in government
- When are prospective parents or parents of infants most receptive to information
about vaccines (e.g., during prenatal care visits, at the first well-child visit,
Answering these questions will require longitudinal studies within individual communities
to assess how and when parents arrive at vaccination decisions, how their attitudes
and beliefs change over time, and what information sources (e.g., primary care physicians,
Internet/television, social media, local social networks, family and friends, etc.)
most strongly influence their decisions. These studies should sample prospective
parents in young adulthood, expectant parents during pregnancy, parents immediately
after the birth of their children, and parents when their children are scheduled
to receive recommended vaccines.
2. The Medical Encounter
- How can providers best determine parents’ attitudes about immunization?
- How can providers best respond to parental concerns?
- How can providers best present their science-based vaccine recommendations?
- Could a “checklist” for providers be developed to improve communications with parents?
Researchers should evaluate the effectiveness of communication strategies, including
negotiation, used by all clinicians when discussing childhood vaccination with parents.
A clearinghouse of vaccination-related interventions and innovations, drawing on
data from state and local immunization managers and from other countries, and how
these interventions affect uptake of childhood vaccinations, would facilitate such
3. At-Risk Communities
- What are the most effective ways to identify geographic communities at increased
risk of vaccine-preventable disease outbreaks?
- Are there common features among these communities?
- Do social networks play a different role in these communities than in communities
at lower risk for vaccine-preventable disease outbreaks?
- How does peer-to-peer communication influence vaccine acceptance and uptake?
- In the case of communities or demographic groups that are apt to delay or refuse
childhood vaccinations, what types of community-based interventions would have the
largest effect on vaccine uptake?
A CALL FOR ACTION
Childhood vaccination is a cornerstone of a healthy society—an essential bulwark
against infections that, though currently in the shadows, inevitably reappear when
public health defenses are down. In the United States, overall childhood vaccination
coverage is still strong. But recent increases in immunization delay and refusal—and
the resulting cases and outbreaks of preventable diseases—are a harbinger of danger.
Reversing this situation will require that public health leaders develop and promote
evidence-based actions to increase the optimal use of vaccines. Therefore, it is
critical that government agencies and private foundations support and prioritize
cross-disciplinary research on immunization decision-making, as well as evaluate
the effectiveness of health communication strategies. The research agenda presented
here provides a foundation for enhancing both parent-provider and health agency
communication. At stake is not only the physical health of the U.S. population,
but also our nation’s basic trust in science-based public health recommendations.
A modern and well-functioning society can afford no less.
E. Sugarman et al., “Measles Outbreak in a Highly Vaccinated Population, San Diego,
2008: Role of the Intentionally Undervaccinated,” Pediatrics 125 (4) (April
1, 2010): 747–755; originally published online March 22, 2010, doi: 10.1542/peds.2009-1653.