Parental refusal of vaccination

Vaccine Refusal: AAP Changes Stance on Patient Dismissal

The American Academy of Pediatrics (AAP) has modified its position on vaccine refusal and now says that pediatricians can opt to dismiss parents who refuse vaccines, though only as a last resort.

In a new clinical report, the APP describes the increase in vaccine hesitancy among parents. Approximately 75% of pediatricians in 2006 met with parents who refused a vaccine, compared with 87% of pediatricians in 2013.

According to the report, one-on-one discussion with a trusted pediatrician is the most likely avenue for changing a parent’s stance on vaccines. An observational study found that 47% of parents eventually consented to vaccines after initial refusal when their physicians continued to engage with them on the issue.

The report includes details on the reasons parents refuse vaccines and offers resources that pediatricians can use to educate vaccine-hesitant parents. For example, parents often say they are concerned about overwhelming their child’s immune system, but a table in the clinical report shows that all of the current childhood vaccines have significantly fewer immunogenic proteins and polysaccharides than earlier vaccines. Giving parents a copy of the table may help to reassure them about the safety of the vaccine schedule.

In addition, the report discusses options for reducing pain, and includes extensive information on the process for testing and licensure of vaccines.

However, educating patients about vaccines can be time consuming and may decrease the time pediatricians can spend with other patients. In addition, unimmunized children may expose other patients to vaccine-preventable diseases. The AAP previously did not endorse dismissal, but concerns from practitioners led the report’s author to include it as a last resort in the pediatrician’s toolbox.

"The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view," the authors wrote.

The report describes the limited circumstances for this approach.

  • Dismissal must be in accordance with state laws on abandonment of patients.
  • Parents or guardians should be officially notified and provided with information about finding a new physician.
  • The office policy on vaccinations and dismissal should be clearly stated to the family.
  • The pediatrician should make multiple attempts to educate the family before considering dismissal.
  • The dismissing physician should continue treating the patient and providing emergency care for at least 30 days.
  • If the pediatrician is in an area of the country with limited access to other primary care providers, dismissal of a patient could leave children without adequate health care. In such circumstances, the pediatrician should continue to provide care.

The report’s authors conclude by emphasizing the opportunity pediatricians have for bettering the lives of their patients. “Most parents need and want education about the best way to provide care for their children, including vaccinations. Dealing with vaccine hesitancy is a wonderful opportunity to continue to provide this information and education to families,” they stated.

—Lauren LeBano


1. Edwards KM, Hackell JM, the Committee on Infectious Diseases, the Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. August 2016. From the American Academy of Pediatrics. Clinical Report.