Vaccination Refusal: How to Counsel the Vaccine-Hesitant Parent

Eastern Virginia Medical School

Dr Harrington is associate professor of pediatrics at Eastern Virginia Medical School and Children’s Hospital of The King’s Daughters in Norfolk, Va. He is also a member of the editorial board of Consultant For Pediatricians.

Editor's Note: You can see Dr Harrington speaking with Project Immunize Virginia on You Tube at Project Immunize Virginia is a statewide immunization coalition with a mission to promote timely immunizations across the lifespan. It focuses on education (both public and professional) as well as advocacy. It was formed in 1995 as a private/public partnership. Its efforts are suppoted by both the Virginia Department of Health and Eastern Virginia Medical School.

Author's Note: I think this article is a nice complement to the recent article by Dempsey and colleagues "Alternative vaccination schedule preferences among parents of young children" (Pediatrics. 2011;128:848-856). The authors highlight that more than 1 of 10 parents use an alternative vaccination schedule.

ABSTRACT: To adequately address parental concerns about vaccines, it is important to understand where the fear of vaccines stems from. Several misconceptions parents have about vaccines leading to vaccine delay or refusal include the belief that vaccine-preventable diseases no longer pose any risk, that multiple vaccines overload the child’s immune system, that vaccines cause autism, and that certain ingredients in vaccines are dangerous. Vaccine exemption based on religious or personal belief has increased in certain states and has led to pockets of severely under-vaccinated areas that are at risk for outbreaks. Initiation of a dialogue about vaccines early in the child’s life can detect any underlying hesitancy or misinformation that can be corrected. Communication that is respectful, nonpatronizing, and nonconfrontational can help reassure parents and reduce vaccine hesitancy.

“I think I would rather not vaccinate my child today.” Sometimes this statement surprises the busy pediatrician, other times we can see it coming a mile away. Vaccination refusal occurs annually in almost every practice where children receive vaccines.1 The decision to vaccinate a child can be an emotional one for the parents.2 In the National Immunization Survey of 2002–2003, 28% of parents had some doubts about vaccines that caused them to: immunize but still feel uncomfortable (9%), delay vaccination (13%), or refuse vaccination (6%).3

So what are the characteristics of a non-vaccinator? Non-vaccinators tend to be female, college graduates, and white, they often hold alternative health beliefs or have a direct experience with an assumed adverse event (child or relative with autism or someone who had a seizure).4

The vast majority of parents (90%) believe that vaccines prevent diseases and 76% of them trust their doctor.5 Yet within those strong numbers are parents who are still somewhat skeptical and believe that a child can be harmed by vaccines. When dealing with vaccine-hesitant parents, we can take the authoritarian approach and state, “If you don’t vaccinate, you are out of the practice!” However, the infants and children of those parents remain unvaccinated and have to go somewhere. Once patients are dismissed, the pediatrician loses the opportunity to vaccinate this child, and many parents who initially refuse vaccination but continue a relationship with their pediatrician eventually immunize (Table).6

Vaccination refusalMost pediatricians use the persuasion technique recommended by the American Academy of Pediatrics (AAP), which follows the collaborative model. Using this technique, a response to a vaccine-hesitant parent might go something like, “I realize that there are messages in the media about vaccines and possible harm, which can be confusing, but I want to do my best for your child and that means helping to protect him with a vaccine.” Obviously, this technique also has its pros and cons. Here, I review the reasons for vaccine hesitancy and discuss ways to help improve communication with parents and promote vaccination.


To help streamline your approach to vaccine counseling, it may be useful to categorize vaccine-hesitant parents into the 5 loosely organized groups identified by Halperin7:

Uninformed but educable and seek information to counter any anti-vaccine information.

Misinformed but correctable and not fully aware of vaccine benefits.

Well-read and open-minded, wishes to discuss the issues intelligently, with consideration of advantages and disadvantages.

Strongly vaccine-hesitant, willing to listen to the other side of the argument but unlikely to change viewpoint right away.

Strong-willed and committed, wants to convince the provider to agree with their argument against vaccines.

The parents in the first 4 groups can be reasoned with. The parents in the last group are extremely difficult to counsel. Under most circumstances, they may be ones you consider discharging from your practice. These parents should definitely be provided the AAP’s “Refusal to Vaccinate” form if you plan on having them remain in the practice.8


To adequately address parental concerns about vaccines, it is important to understand where the fear of vaccines stems from. The list below highlights several common misconceptions among parents; however, the pediatrician must individualize the counseling for each family and avoid making erroneous assumptions about a parent’s beliefs or concerns.9

Belief that vaccine-preventable diseases no longer pose any risk

Because of the success of vaccines, many parents and even young physicians have not seen cases of measles, chickenpox, or Haemophilus influenzae type b (Hib) infection. This has caused parents and some physicians to feel complacent about the risks. One physician, Bob Sears, published his own nonevidenced-based delayed immunization schedule, The Vaccine Book: Making the Right Decisions for Your Child, which unfortunately gained acceptance with some anti-vaccine and vaccine-hesitant parent groups. Dr Sears has been soundly criticized for perpetuating this complacency that puts so many children at risk.10

The recent resurgence in measles, pertussis, and Hib infections proves that vaccine refusal and delay can have deadly consequences. A record number of measles cases (156) were reported in the United States in the first half 2011.11 In 2008, invasive Hib disease occurred in 5 unvaccinated or under-vaccinated children in Minnesota, one of whom died.12 Another case of Hib meningitis was reported in Maine in 2009.13 In 2010, 1337 cases of pertussis were reported in California, 5 of which involved infants younger than 2 months of age who died.14 Making parents aware of these statistics may be enough to convince them that their decision not to vaccinate is putting their child’s life at risk. Unfortunately, the benefits to the community are not obvious to a child or parent until a vaccine-preventable disease develops in someone within their family or social network.

Doubt about the vaccine safety profile

vaccination refusalIt is impossible to live life risk-free: there are risks in driving your car, flying on an airplane, and yes being vaccinated. However, one can significantly increase their risk of injury by not wearing a seat belt or by not receiving a vaccine. Parents should be made aware that any vaccine can cause adverse effects and that the risk of serious vaccine-associated complications is very low. For instance, the risk of brain damage after receiving the measles, mumps, and rubella (MMR) vaccine versus the risk of encephalitis from natural measles infection is illustrated in Figure 1.15

To reassure skeptical parents, pediatricians can share their own experience; whether any children in their practice have had serious adverse effects after receiving the vaccine. They can also take extra time to review the vaccine information handout and refer parents to the CDC Web site on “Possible Side-effects from Vaccines.”16

Belief that multiple vaccines overload the child’s immune system

Parents are unaware of the fact that children are exposed to thousands of antigens every day on common surfaces, such as toys, doorknobs, and playground equipment. Patients certainly have more shots than they did years ago; however, the total number of antigens they receive is smaller than in the past (eg, smallpox vaccine had more than 200 antigens in 1 injection).17 Children who receive all the required vaccines are exposed to fewer than 130 antigens.18

Vaccinated children do not appear to have any increase in adverse effects from all the vaccines they receive. A recent study that evaluated 1047 children between ages 7 and 10 years who had their shots on time before age 2 years found no increase in neurodevelopmental problems, including tics, poor memory, stuttering, and slowed response to stimuli.19

Belief that certain vaccines have been linked to autism

The earlier studies that proposed a vaccine-autism link have now been retracted and debunked. Many well-designed trials have shown no causal relationship between vaccines and autism.20 Because of the many vaccines required within the first 2 years of life, people want to believe that any adverse health event before age 2 years can be ascribed to vaccines. Although vaccines are given around the same time that autism becomes apparent, it does not mean that vaccines cause autism. When describing the difference between causal and temporal, I often use the analogy of the rooster who crows every morning and believes he makes the sun come up. When the rooster has laryngitis, he  realizes that the sun still rises despite his inability to crow.

Classic autism is generally apparent in children by the age of 18 months. The signs of abnormal speech, poor joint attention skills, and repetitive and restrictive behaviors may predate this time. It is easy for parents who notice a loss of developmental milestones (regressive autism) in their child around the time of his or her last vaccination to surmise that the vaccine may have been the cause. Current research suggests that genetics and the environment play a collaborative role in the development of autism. Without a definitive cause of autism, vaccines will probably continue to be a target because of the timing of when they are given, even though they have been exonerated by research.

Belief that certain ingredients (thimerosal and aluminum salts) in vaccines are dangerous

There is no scientific evidence that thimerosal in vaccines is harmful or associated with autism.21 Although other vaccines may have contained thimerosal in the past, the MMR vaccine never contained thimerosal or any other form of mercury. In 2001, vaccine manufacturers removed thimerosal from all their products, except multidose vials. Yet, the number of children with neurodevelopmental problems, such as autism and attention-deficit hyperactivity disorder, has continued to rise.

Aluminum salts may be included in some vaccines as an adjuvant to enhance the immune response. Aluminum adjuvant-containing vaccines have a demonstrated safety profile and associated local reactions are uncommon.22 The most common source of exposure to aluminum is actually in our daily exposure to food and water.


All states have a vaccine exemption for any child with a medical contraindication, such as an immune disorder. Some states have adopted 2 additional types of exemptions, which can be used to avoid school vaccination (Figure 2). These allow parents to opt-out if their religion opposes any medical interventions or if they are philosophically or personally opposed to the idea of mandatory vaccines.

vaccination refusal
The states that have adopted the religious and personal belief exemptions have experienced an increase in vaccine exemptions for these reasons. A study from 2006 showed that where states allowed this new opt-out policy, the number of exemptions rose from 1% to 2.5% between 1991 and 2004.23 These exemptions have caused pockets of severely under-vaccinated areas in the United States that are now at risk for outbreaks. One retrospective study found that children aged 5 to 19 years who exempted MMR vaccination were 35 times more likely to become infected with measles than those who were vaccinated.24 This trend in vaccine exemption is discussed in detail in the book Deadly Choices: How the Anti-Vaccine Movement Threatens Us All by Dr Paul Offit.25

Clinicians in under-vaccinated areas will need to be vigilant for rashes and other signs of illness suggestive of a vaccine-preventable disease. They must also have protocols to protect the patients in their practice who cannot be vaccinated (small infants, immunocompromised and oncology patients).


Most of the information that vaccine-hesitant parents find on vaccines comes from the Internet. You should not simply discount these parents’ research efforts, but rather point them to more authoritative sources that you trust. A list of recommended online resources is provided at the end of this article. For some parents, it may be helpful to stress that when searching the Internet for information on vaccines, one can stumble across a number of reputable and not-so-reputable sources. The way information is presented on some Web sites may appear to be valid and accurate, when in fact it has no scientific backing. The pediatrician can help by explaining why the recommended online resources are trustworthy and by encouraging parents to ask questions.


The following 8 steps can help improve communication and decrease vaccine hesitancy:

Initiate a dialogue about vaccines early (at the infant’s first visit) to find any underlying hesitancy or misinformation that can be corrected.

Distribute the Vaccine Information Sheets early, usually at the 1-month visit, so parents have time to consider their unspoken questions.

Solicit and welcome questions during vaccine visits and take time to listen (make eye contact), don’t patronize.

Don’t get offended and don’t offend.

Acknowledge benefits and possible risks.

Use clear and simple language.

Respect the parent’s authority and develop the ability to have shared decision making.

Have your practice emphasize the reduction of stress and pain of the shots through the use of sucrose and/or swaddling.

If we can help parents be less vaccine-hesitant and not refuse vaccines, we should be able to prevent an outbreak of vaccine-preventable diseases.

Recommended Online Resources 

For health care professionals
Centers for Disease Control and Prevention
 Vaccine Information Statements (free)
Immunization Action Coalition
National Foundation for Infectious Disease
For parents
American Academy of Pediatrics
Centers for Disease Control and Prevention
National Network for Immunization Information
Vaccinate Your Baby