Christopher Futcher / iStockphoto
NURSES AS PRIMARY ADVOCATES FOR
IMMUNIZATION
ADHERENCE Gail Holland Wade, PhD, RN
Abstract Immunizations, one of the greatest public health achievements, are at times hindered by a history of powerful biological, social, and cultural reactions from the public. State laws require immunizations for school entry, however some parents choose a nonmedical exemption for their children. Although many vaccine-preventable diseases are practically extinct in the United States, nurses have a unique role in increasing parents’ understanding that herd immunity may not protect their unimmunized children. By listening to and addressing parents’ concerns about immunizations, nurses can dispel misconceptions and help change parents’ perceptions about the risks associated with immunizations. Key words: Immunization laws; Immunizations; Nonmedical exemptions; Vaccinations.
November/December 2014
MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
351
V
accine development, considered as one of the 10 greatest accomplishments of public health, is at times hindered by a history of powerful biological, social, and cultural reactions (Centers for Disease Control and Prevention [CDC], 2011b; Stern & Markel, 2005). The amount and complexity of information about vaccines continue to expand, leading to a poor understanding of immunization issues and systems by the public and healthcare professionals. Since the origin of the Healthy People initiatives, immunizations have been a priority. Several of the Healthy People 2020 objectives specifically address increasing immunization rates in infants, young children, and adolescents with an emphasis on a fully operational, population-based immunization information system (United States Department of Health & Human Services, 2013). Although data regarding vaccination coverage in children are promising, variations occur when parental refusal of vaccinations result in high numbers of unvaccinated or undervaccinated children (CDC, 2012). Nurses can influence parents’ decisions about immunizing their children. To communicate with parents, nurses must be able to effectively converse about the risk of disease versus the risk of a vaccine-related adverse event. This article addresses issues associated with refusal to immunize children and how nurses can influence immunization decisions. Following a review of immunization regulations and exemptions, recommendations for children are discussed. Finally, common concerns of parents are explored and approaches nurses can use to respond to these concerns and improve immunization adherence are addressed.
Immunization Regulations and Exemptions Since early immunization laws were instituted, immunizations have been a controversial topic (Salmon, 2003). Debate about individual rights versus protection of the public continues. Arguments for immunizations focus on the concept of herd immunity whereby immunization of 85% to 95% of the population protects those who are not immunized. Those opposed to immunizations counter that immunization mandates violate personal freedoms and the rights of parents to make decisions. Most of the current laws, which are the purview of states, focus on immunization requirements for entry into school (Salmon, 2003). As of 1980, all 50 states require certain immunizations before entering school (Table 1 of Resources). Unless these laws are enforced however, community immunity will be difficult to achieve. To support individual freedom of choice, exemptions from immunizations for medical, philosophical, or religious reasons are allowed (Salmon, 2003; Welborn, 2005). All states permit medical exemptions for immune-compromised individuals, those who have allergic reactions to vaccine components, those who have moderate-to-severe illness, and other medical contraindications. All states except Mississippi and West Virginia allow religious exemptions (National Vaccine Information Center, 2014). 352
volume 39 |
number 6
Nonmedical exemptions, which represent about 2% of the population of the United States, vary by states, as do the documentation requirements (Omer, Richards, Ward, & Bednarczyk, 2012). Nonmedical exemptions include those for “philosophical” and “religious” reasons. Philosophical exemptions, sometimes referred to as “conscientious” exemptions, reflect objections other than religious beliefs (Blank, Caplan, & Constable, 2013). A recent study indicated that most states do not have a definition for religious exemption, leaving open to interpretation the meaning of this type of exemption (Blank et al., 2013). Furthermore, a majority of states accept religious exemptions without question. Some states require parents to sign a waiver, whereas other states require no specific documentation. States with vague nonspecific exemption procedures had exemption rates that were twice as high as those in states with more stringent procedures. Over the past decade, the percentage of nonmedical exemptions has increased leaving unprotected or susceptible people particularly vulnerable to Vaccine Preventable Diseases (Blank et al., 2013).
Immunization Recommendations and Schedules Since 1995, immunization schedules are updated annually by the CDC’s Advisory Committee on Immunization Practices (ACIP) (CDC, 2014a). Although these schedules are recommended and not required, state immunization laws generally follow the ACIP recommendations (Welborn, 2005). Recommended schedules published in 2014 are available for ages zero through 18 on the CDC Web site (www.cdc.gov/mmwr/preview/mmwrhtml/su6201a2. htm). For missed immunizations, a catch-up schedule is available. Annual updates provide information about who should receive each vaccine and at what age, the number of doses needed, the interval between doses, and about any new vaccines or vaccine combinations. For infants and young children, the vaccine schedule follows the American Academy of Pediatrics (AAP) schedule for well-child visits. In the first 6 months, visits are scheduled every 2 months and increase to every 3 months until 18 months. Before entering school, a health visit with scheduled immunizations is recommended. If a vaccine is not administered as scheduled, it should be administered at the next visit when feasible. Regardless of the amount of time between vaccines, the series does not need to be restarted (CDC, 2014a). For the age group from birth through 6 years, there are 15 diseases for which vaccines are recommended. To increase effectiveness, some vaccines need to be given more than once. Combination vaccines are generally preferred over separate injections of equivalent component vaccines and should be based on parents’ preference, the potential for adverse events, an assessment of the number of injections needed, vaccine availability, the likelihood of improved coverage, and whether the patient will return for another vaccine (CDC, 2011a). Some vaccine combinations require different schedules than the monovalent November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PhotoEuphoria / iStockphoto
Acceptance of the importance of immunizations is at times hindered by a history of powerful biological, social, and cultural reactions from the public.
vaccine, which may be confusing when a child is treated by multiple healthcare providers. However, if the child has already received the recommended vaccinations for some of the components in a combination vaccine, administering the extra vaccines in the combination is acceptable. Although children from 7 to 18 years of age have less frequent well-child visits than younger children, protection from VPDs is still needed. Some of the protection from earlier vaccines may wane making children vulnerable to VPDs. If primary vaccination coverage is incomplete, there will be a resurgence of VPDs (Blendell & Fehr, 2012). Except for the annual influenza vaccines, schedules for children from 7 to 10 are primarily catch-up schedules. The health visit for 11- and 12-year-olds involves three recommended immunizations as well as the annual influenza vaccine. These vaccines include the tetanus, diphtheria, and accellular pertussis vaccine (Tdap), a vaccine to prevent meningitis (MCV4), and a vaccine to prevent Human papillomavirus (HPV). Regardless of whether the child received the entire DTaP series in early childhood, the Tdap is given as a booster for children over age 7. The Tdap is sometimes confused with the DTaP (Institute for Safe Medication Practices, 2010). If DTaP is given by mistake, the recipient may have a sore arm at the injection site. Should infants and small children receive the Tdap instead of the TDaP, they would be receiving a lower dose of the components than recommended. Because of recent outbreaks of pertussis in infants (3.8/1,000,000 live births in United States), the Tdap is strongly recommended for those adults who have close contact with infants under 12 months of age (Haberling, Holman, Paddock, & Murphy, 2009). Many healthcare providers believe that certain conditions such as a low-grade fever preclude children from receiving vaccinations (AAP, 2013). Other common conditions that are often perceived as contraindicated include diarrhea, minor upper respiratory illnesses with or without fever, otitis media, mild-to-moderate local reactions to a previous dose of vaccine, current antibiotic treatment, and convalescence from an acute illness (CDC, 2011a). With moderate-to-severe acute illnesses, vaccinations are deferred primarily to prevent diagnostic confusion between manifestations of illness and an adverse event. The only contraindication applicable to all vaccines is a history of a severe reaction to a previous November/December 2014
dose of the same vaccine or vaccine component. However, in most cases these individuals would benefit from protection with other vaccines (Shepherd & Grabenstein, 2001). Generally live attenuated vaccines such as the varicella zoster, and MMR are not recommended for individuals who are pregnant or immune-compromised.
Parental Concerns About Immunization Although most concerns about vaccine safety are expressed by parents of underimmunized children, parents who immunize their children also have concerns (Freed, Clark, Butchart, Singer, & Davis, 2010). Many parents believe that protection from infectious disease through immunization is common practice and are less concerned with the consequences of VPDs than any risks associated with vaccines. Newer vaccines such as HPV and meningococcal conjugate vaccines are more likely to be refused due to lack of trust (Freed et al., 2010). An understanding of why parents refuse to vaccinate their children could lead to better communication and less need for nonmedical exemptions. Concerns about the safety of vaccines are accentuated by the rapid speed by which information and misinformation about vaccines and vaccine-preventable diseases are spread via the Internet. Over the past several years, there have been many antivaccination activists on the World Wide Web (Davies, Chapman, & Leask, 2002). Web sites, blogs, social networks, and even YouTube add to the burgeoning misinformation about vaccinations. Simply promoting the use of vaccines is no longer effective as individuals and families try to make informed decisions amidst a maelstrom of conflicting messages. In a national survey of the prevalence of vaccine refusal and specific parental safety concerns, more than half of the parents (n = 1552) expressed concerns about serious adverse effects (Freed et al., 2010). Women were more likely to believe that some vaccines caused autism in healthy children and would refuse a recommended vaccine. Although Hispanic women were more likely than White or Black parents to believe that some vaccines were associated with autism, this group was more likely to follow the recommendations than were the other groups. Black parents, however, were more likely than White and Hispanic MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
353
Table 1. Resources for Providers and Parents Resources for Providers:
Type of resource/website
Safety of Vaccines Used for Routine Immunization in the United States, Agency for www.effectivehealthcare.ahrq.gov/reports/final.cfm Healthcare Research and Quality (Evidence Report/Technology Assessment No. 215) Vaccine Information Statements (VIS)
wwwt.cdc.gov/vaccines/pubs/vis/default.htm
Vaccine for Children Program
www.cdc.gov/vaccines/programs/vfc/index.html
Screening Checklist for Contraindications for Vaccines for Children and Teens
www.immunize.org/catg.d/p4060.pdf
Talking with parents about immunizations
www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html www.cdc.gov/vaccines/hcp/patient-ed/conversations/conv-materials.html
Form for documenting parental refusal of vaccination
http://www2.aap.org/immunization/pediatricians/pdf/refusaltovaccinate.pdf
Responding to common misconceptions about immunizations
www.cdc.gov/vaccines/vac-gen/6mishome.htm
Guide to vaccine contraindications and precautions
www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm
Vaccine Adverse Reporting Systems (VAERS)
www.vaers.hhs.gov/index
Vaccines for your children
www.cdc.gov/vaccines/parents/index.html
Parents’ frequently asked questions
http://www2.aap.org/immunization/families/faq/FAQ_Safety.pdf
Facts for parents about vaccine safety
http://www2.aap.org/advocacy/releases/autismparentfacts.htm
parents to refuse a recommended vaccine. Rationales for refusals by population groups were not identified. The most highly publicized challenge to immunization adherence is the association of the MMR vaccine with autism (Smith, 2010). More than one in five parents believe that some vaccines cause autism in otherwise healthy children (Freed et al., 2010). Despite evidence that the threat was unfounded, some continue to refuse the MMR. As a consequence, measles epidemics have erupted as the disease is carried into the country by immigrants and international travelers. In the first 3 months of 2014, 288 cases of measles were reported to the CDC (CDC Press Release, 2014b). This incidence is the largest reported since 1994. A lack of trust about vaccine safety continues to exist with other vaccines as well. Although the acellular pertussis component replaced the original pertussis component and eliminated most adverse events from the first DPT vaccinations, a lack of trust for this vaccine continues and outbreaks persist. In 2010, an outbreak of pertussis in California sickened 6,200 people and resulted in the death of 10 infants (California Department of Public Health, 2010). Some parents question the need for the Hepatitis B vaccine in infancy as they perceive the vaccine as primarily for those who engage in intravenous drug use and high-risk sexual behavior. The American Academy of Pediatrics (AAP, 2013) recommends that parents be advised that the vaccine ensures protection throughout 354
volume 39 |
number 6
life from a virus that often has no symptoms and can lead to premature liver diseases, cancer, and death. Despite recent influenza outbreaks, parents question the need for an annual influenza vaccine. Parents may not be aware that immunity to one strain of influenza does not provide protection against new strains of the virus. Some parents believe that chicken pox is a harmless childhood disease and are unaware of the associated sequela. Although the vaccine may not provide total immunity, it does prevent severe chickenpox in over 95% (AAP, 2013). When there is a lack of reliable information from healthcare providers and confusing information from the media, parents may elect a nonmedical exemption for their children. In states where policies for nonmedical exemptions are unrestrictive, parents may request an exemption based on inconvenience (Blank et al., 2013). Nurses have a vital role in decreasing nonmedical exemptions by influencing parents’ decisions about vaccinating their children. In a secondary data analysis from the National Immunization Parental Knowledge survey (2001–2002) of parents (n = 7695) of children 19 to 35 months, Smith, Kennedy, Wooten, Gust, and Pickering (2006) concluded that parents who believed that providers were influential in helping them make the decision to immunize their child were twice as likely to respond that vaccines were safe for children. Among those who believed that vaccines were not safe, respondents indicated that their decision to vaccinate was influenced by their healthcare provider. November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Immunization Adherence As trusted healthcare providers, nurses are in a unique position to break down barriers to immunizations by addressing parental concerns about vaccine safety. Nurses need to examine their own attitudes and beliefs about immunizations to ensure that they are giving positive information to parents. A survey of knowledge, attitudes, and beliefs of school nurses and other school personnel revealed that children attending schools that had school nurses were significantly less likely to have an immunization exemption than those who attended a school without a school nurse (Salmon et al., 2004). Nurses were more likely than nonnurse school personnel to believe in the effectiveness and safety of vaccination. Nurses, who practice in a variety of settings, must use every encounter with parents to espouse the benefits of immunizations and dispel any myths. According to an innovative UNICEF working paper, there has been a rise in antivaccination sentiment in Europe indicating that parents are using social media networks to make decisions about immunizing their children (UNICEF, 2013). Nurses may influence parental decision about immunizations by responding to their concerns and directing them to Web sites that contain reliable information. Tips for selecting appropriate immunization Web sites can be accessed by going to www. immunizationinfo.org/parents/evaluating-information-web Building relationships with parents that inspire trust may be more important than the information provided (Leask et al., 2012). Open-ended questions and active listening should be used to assess parent’s concerns. Once concerns are addressed, nurses should update the immunization history and inquire about any past adverse events related to immunizations. Before administering immunizations, nurses should screen for contraindications or precautions to immunization. The Immunization Coalition provides an easily adaptable screening tool for contraindications and precautions (Table 1 of Resources). Prior to administering vaccines, nurses must give parents a written copy of the appropriate vaccine information statements (VIS) (CDC National Vaccine Program Office, 2013). The VIS contains the risks and benefits for each immunization. Copies of the VIS, in English, Spanish, and other languages, can be downloaded from the CDC Web site (Table 1 of Resources). Should an adverse event occur, nurses must report these events through the Vaccine Adverse Events Reporting System (VAERS), a national vaccine safety surveillance program for monitoring information about vaccine adverse events (Table 1 of Resources). One of the biggest challenges for nurses is financial and behavioral barriers to immunizations. Financial barriers may be related to expenses for vaccines and provider payment mechanisms. Through the Vaccines for Children program, eligible children can receive, free of charge, all recommended vaccines (Table 1 of Resources). Behavioral and attitudinal barriers are often more diffi cult to remove. Behavioral barriers may be related to cultural, religious, or personal beliefs about immunizations (AAP, 2013). Because every situation is unique, nurses need to determine parents’ positions on immuNovember/December 2014
nizations. Recently, Leask et al. (2012) identified five parental positions on vaccinations: unquestioning acceptor (30–40%), cautious acceptor (25–35%), hesitant (20–30%), late or selective vaccinator (2–27%), and refuser (≤2%). Approaches to parents should be based on parents’ readiness to vaccinate their children. For the hesitant, late or selective vaccinators, or refusers, nurses should use a guiding style that elicits the parent’s own motivations to vaccinate. At all times, the nurse should avoid confrontational approaches. Many parents believe that VPDs are not serious illnesses that warrant vaccination (Blendell & Fehr, 2012). Nurses can provide CDC data about rising rates of VPDs in the community with evidence that demonstrates vaccine safety. As trusted healthcare providers, nurses can influence parents’ decisions about immunizing their children and help to prevent disease outbreaks. Parents need information about the effect of disease outbreaks on their children’s ability to attend school. When an outbreak occurs, unvaccinated children are not permitted to attend school. Outbreaks tend to occur in waves, meaning that an unvaccinated child could miss several months of school (CDC National Vaccine Program Office, 2013). Despite evidence supporting the safety and efficacy of immunizations, nonmedical exemptions continue to rise (Blank et al., 2013). One approach to minimizing exemptions may be to require parents considering a nonmedical exemption to attend educational sessions given by nurses or other healthcare providers (Salmon, 2003). Blank et al. (2013) suggest that policy makers consider strengthening nonmedical exemption procedures and encouraging annual educational sessions for parents who refuse to immunize their children. Although nurses and other healthcare providers can guide parents’ decisions about immunizations, parents are ultimately responsible. If after careful discussion, parents still refuse immunizations for their children, nurses should document the reasons for refusing the immunizations and revisit the issue during future healthcare encounter. Outreach to ensure that parents are taking advantage of immunization opportunities is needed. Information about immunizations needs to include more than reminders about recommended appointments. Nontraditional approaches such as social marketing can be used to reach the public. Social marketing may increase vaccination rates by using commercial marketing techniques, behavior change theory, and social psychology to capture the public’s attention and motivate change (Opel, Diekema, Lee, & Marcuse, 2009). Because social marketing strategies appeal to emotion, this strategy may be an effective response to the antivaccination movement. California has used such a campaign and Washington is pursing a campaign to increase timely immunizations among children from birth to age 24 months.
Conclusions Even though VPDs are practically extinct in the United States, nurses need to help parents understand that the risk of the disease is still very real. More parents are refusing vaccines, and outbreaks of VPDs remain a problem. Given MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
355
the various reasons for parental refusal of immunizations, a “one-size-fits-all approach” ignores the realities of how people are persuaded. Nurses can take the lead as active advocates for immunizations by recognizing parents’ positions on immunizations, building trust, and adapting educational materials in a way that effectively addresses their concerns. Many approaches to improving immunization adherence have been identified in the literature, yet evidence is needed to test approaches that are successful in decreasing nonmedical exemptions. Nurses can also proactively influence public policy about nonmedical exemptions. With the Affordable Care Act, more people will have access to immunizations. Public health workers, health insurers, and healthcare providers will need to work together to ensure immunization coverage. A comprehensive resource was published in July 1, 2014, by the Agency for Healthcare Research and Quality (AHRQ); Safety of Vaccines Used for Routine Immunization in the United States (Maglione et al., 2014). This AHRQ Evidence Report/Technology Assessment (Maglione et al., 2014) is highly recommended as a resource for healthcare providers to assist them in providing current, accurate, and thorough information about vaccines used for routine vaccination in the United States to parents. Although many resources about vaccines are available, information is not reaching parents in an effective or convincing way (Freed et al., 2010). The media often reports stories of individuals who developed a medical problem after being vaccinated. Yet, millions of children are vaccinated and protected against VPDs without any adverse events. Although these success stories may not be newsworthy, they are evidence of the success of immunizations. Support and encouragement by nurses to parents who are in the process of a decision about vaccination of their child that is based on accurate information can promote best practice and a healthy childhood outcome. ✜ Gail Holland Wade is an Associate Professor, School of Nursing, University of Delaware, Newark, DE. The author can be reached via e-mail at [email protected] The author declares no conflict of interest. DOI:10.1097/NMC.0000000000000083 References American Academy of Pediatrics. (2013). Addressing common concerns of vaccine-hesitant parents. Elk Grove Village, IL: Author. Retrieved June 27, 2014 from http://www2.aap.org/immunization/ pediatricians/pdf/vaccine-hesitant%20parent_final.pdf Blank, N. R., Caplan, A. L., & Constable, C. (2013). Exempting schoolchildren from immunizations: States with few barriers had highest rates of nonmedical exemptions. Health Affairs, 32(7), 1282-1290. doi:10.1377/hlthaff.2013.0239 Blendell, R. L., & Fehr, J. L. (2012). Discussing vaccination with concerned patients: an evidence-based resource for healthcare providers. Journal of Perinatal & Neonatal Nursing, 26(3), 230-241. doi:10.1097/JPN.0b013e3182611b7b California Department of Public Health. (2010). Pertussis report. Sacramento, CA: Author. Retrieved June 27, 2014 from www.cdph.ca.gov/ programs/immunize/Documents/PertussisReport2010-12-15.pdf CDC National Vaccine Program Office. (2013). Immunization laws. Retrieved from http://www.hhs.gov/nvpo/law.htm. 29 July 2013. Centers for Disease Control and Prevention. (2011a). General recommendations on immunization: Recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep, 60(2), 1-61. www.cdc.gov/mmwr/pdf/rr/rr6002.pdf
356
volume 39 |
number 6
Centers for Disease Control and Prevention. (2011b). Ten great public health achievements-United States, 2001-2010. MMWR Morb Mortal Wkly Rep, 60(19), 619-623. Retrieved June 27, 2014 from www. cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm Centers for Disease Control and Prevention. (2012). National, state, and local area vaccination coverage among children aged 19-35 monthsUnited States, 2011. MMWR Morb Mortal Wkly Rep, 61(35), 689-696. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6135a1.htm?s_ cid=mm6135a1_w Centers for Disease Control and Prevention. (2014a). Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older—United States, 2014. MMWR Morb Mortal Wkly Rep, 63(5), 110-112. Retrieved June 27, 2014 from www.cdc. gov/mmwr/preview/mmwrhtml/mm6305a7.htm?s_cid=mm6305a7_w Centers for Disease Control and Prevention. (2014b). Measles cases in the United States reach 20-year high (Press release May 29, 2014). Retrieved from www.cdc.gov/media/releases/2014/p0529-measles.html Davies, P., Chapman, S., & Leask, J. (2002). Antivaccination activists on the world wide web. Archives of Disease in Childhood, 87(1), 22-25. Freed, G. L., Clark, S. J., Butchart, A. T., Singer, D. C., & Davis, M. M. (2010). Parental vaccine safety concerns in 2009. Pediatrics, 125(4), 654-659. doi:10.1542/peds.2009-1962 Haberling, D. L., Holman, R. C., Paddock, C. D., & Murphy, T. V. (2009). Infant and maternal risk factors for pertussis-related infant mortality in the United States, 1999 to 2004. Pediatric Infectious Disease Journal, 28(3), 194-198. doi:10.1097/INF.0b013e31818c9032 Institute for Safe Medication Practices. (2010). DTaP –Tdap Mix-ups now affecting hundreds of patients (ISMP Medication Safety Alert). Retrieved from www.ismp.org/newsletters/acutecare/articles/20100701.asp Leask, J., Kinnersley, P., Jackson, C., Cheater, F., Bedford, H., & Rowles, G. (2012). Communicating with parents about vaccination: A framework for health professionals. BMC Pediatrics, 12, 154, doi:10.1186/1471-2431-12-154 Maglione, M. A., Gidengil, C., Das, L., Raaen, L., Smith, A., Chari, R., . . ., Goetz, M. B. (2014). Safety of Vaccines Used for Routine Immunization in the United States (Evidence Report/Technology Assessment No. 215). (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 14-E002-EF. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from www.effectivehealthcare.ahrq.gov/reports/final.cfm National Vaccine Information Center. (2014). Vaccine laws. Retrieved from www.nvic.org/vaccine-laws.aspx Omer, S. B., Richards, J. L., Ward, M., & Bednarczyk, R. A. (2012). Vaccination policies and rates of exemption from immunization, 2005-2011. New England Journal of Medicine, 367(12), 1170-1171. doi:10.1056/NEJMc1208306 Opel, D. J., Diekema, D. S., Lee, N. R., & Marcuse, E. K. (2009). Social marketing as a strategy to increase immunization rates. Archives of Pediatrics and Adolescent Medicine, 163(5), 432-437. doi:10.1001/archpediatrics.2009.42 Salmon, D. A. (2003). Mandatory immunization laws and the role of medical, religious and philosophical exemptions. Unpublished commentary, Institute for Vaccine Safety Disease Prevention and control – Department of International Health Johns Hopkins Bloomberg School of Public Health. Salmon, D. A., Moulton, L. H., Omer, S. B., Chace, L. M., Klassen, A., Talebian, P., & Halsey, N. A. (2004). Knowledge, attitudes, and beliefs of school nurses and personnel and associations with nonmedical immunization exemptions. Pediatrics, 113(6), e552-e559. doi:10.1542/peds.113.6.e552 Shepherd, J. E., & Grabenstein, J. D. (2001). Immunizations for high-risk populations. Journal of American Pharmacy Association, 41(6), 839-849. Smith, M. J. (2010). Parental vaccine refusal. Contemporary Pediatrics, 27(2), 36-47. Smith, P. J., Kennedy, A. M., Wooten, K., Gust, D. A., & Pickering, L. K. (2006). Association between health care providers’ influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics, 118(5), e1287-e1292. doi:10.1542/peds.2006-0923 Stern, A. M., & Markel, H. (2005). The history of vaccines and immunization: Familiar patterns, new challenges. Health Affairs, 24(3), 611621. doi:10.1377/hlthaff.24.3.611 UNICEF. (2013). Tracking anti-vaccination sentiment in Eastern European social media networks. Retrieved June 27, 2014 from www. unicef.org/ceecis/media_24017.html United States Department of Health & Human Services. (2013). Healthy People 2020 Topics & Objectives: Immunization and infectious diseases. Retrieved June 27, 2012 from www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=23 Welborn, A. (2005). Mandatory vaccinations: Precedent and current laws. Congressional Research Service: Report for Congress. Report No. RS21414. Retrieved June 27, 2014 from www.infowars.com/ mandatory-vaccinations-precedent-and-current-laws/ November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
NURSES AS PRIMARY ADVOCATES FOR
IMMUNIZATION
ADHERENCE Gail Holland Wade, PhD, RN
Abstract Immunizations, one of the greatest public health achievements, are at times hindered by a history of powerful biological, social, and cultural reactions from the public. State laws require immunizations for school entry, however some parents choose a nonmedical exemption for their children. Although many vaccine-preventable diseases are practically extinct in the United States, nurses have a unique role in increasing parents’ understanding that herd immunity may not protect their unimmunized children. By listening to and addressing parents’ concerns about immunizations, nurses can dispel misconceptions and help change parents’ perceptions about the risks associated with immunizations. Key words: Immunization laws; Immunizations; Nonmedical exemptions; Vaccinations.
November/December 2014
MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
351
V
accine development, considered as one of the 10 greatest accomplishments of public health, is at times hindered by a history of powerful biological, social, and cultural reactions (Centers for Disease Control and Prevention [CDC], 2011b; Stern & Markel, 2005). The amount and complexity of information about vaccines continue to expand, leading to a poor understanding of immunization issues and systems by the public and healthcare professionals. Since the origin of the Healthy People initiatives, immunizations have been a priority. Several of the Healthy People 2020 objectives specifically address increasing immunization rates in infants, young children, and adolescents with an emphasis on a fully operational, population-based immunization information system (United States Department of Health & Human Services, 2013). Although data regarding vaccination coverage in children are promising, variations occur when parental refusal of vaccinations result in high numbers of unvaccinated or undervaccinated children (CDC, 2012). Nurses can influence parents’ decisions about immunizing their children. To communicate with parents, nurses must be able to effectively converse about the risk of disease versus the risk of a vaccine-related adverse event. This article addresses issues associated with refusal to immunize children and how nurses can influence immunization decisions. Following a review of immunization regulations and exemptions, recommendations for children are discussed. Finally, common concerns of parents are explored and approaches nurses can use to respond to these concerns and improve immunization adherence are addressed.
Immunization Regulations and Exemptions Since early immunization laws were instituted, immunizations have been a controversial topic (Salmon, 2003). Debate about individual rights versus protection of the public continues. Arguments for immunizations focus on the concept of herd immunity whereby immunization of 85% to 95% of the population protects those who are not immunized. Those opposed to immunizations counter that immunization mandates violate personal freedoms and the rights of parents to make decisions. Most of the current laws, which are the purview of states, focus on immunization requirements for entry into school (Salmon, 2003). As of 1980, all 50 states require certain immunizations before entering school (Table 1 of Resources). Unless these laws are enforced however, community immunity will be difficult to achieve. To support individual freedom of choice, exemptions from immunizations for medical, philosophical, or religious reasons are allowed (Salmon, 2003; Welborn, 2005). All states permit medical exemptions for immune-compromised individuals, those who have allergic reactions to vaccine components, those who have moderate-to-severe illness, and other medical contraindications. All states except Mississippi and West Virginia allow religious exemptions (National Vaccine Information Center, 2014). 352
volume 39 |
number 6
Nonmedical exemptions, which represent about 2% of the population of the United States, vary by states, as do the documentation requirements (Omer, Richards, Ward, & Bednarczyk, 2012). Nonmedical exemptions include those for “philosophical” and “religious” reasons. Philosophical exemptions, sometimes referred to as “conscientious” exemptions, reflect objections other than religious beliefs (Blank, Caplan, & Constable, 2013). A recent study indicated that most states do not have a definition for religious exemption, leaving open to interpretation the meaning of this type of exemption (Blank et al., 2013). Furthermore, a majority of states accept religious exemptions without question. Some states require parents to sign a waiver, whereas other states require no specific documentation. States with vague nonspecific exemption procedures had exemption rates that were twice as high as those in states with more stringent procedures. Over the past decade, the percentage of nonmedical exemptions has increased leaving unprotected or susceptible people particularly vulnerable to Vaccine Preventable Diseases (Blank et al., 2013).
Immunization Recommendations and Schedules Since 1995, immunization schedules are updated annually by the CDC’s Advisory Committee on Immunization Practices (ACIP) (CDC, 2014a). Although these schedules are recommended and not required, state immunization laws generally follow the ACIP recommendations (Welborn, 2005). Recommended schedules published in 2014 are available for ages zero through 18 on the CDC Web site (www.cdc.gov/mmwr/preview/mmwrhtml/su6201a2. htm). For missed immunizations, a catch-up schedule is available. Annual updates provide information about who should receive each vaccine and at what age, the number of doses needed, the interval between doses, and about any new vaccines or vaccine combinations. For infants and young children, the vaccine schedule follows the American Academy of Pediatrics (AAP) schedule for well-child visits. In the first 6 months, visits are scheduled every 2 months and increase to every 3 months until 18 months. Before entering school, a health visit with scheduled immunizations is recommended. If a vaccine is not administered as scheduled, it should be administered at the next visit when feasible. Regardless of the amount of time between vaccines, the series does not need to be restarted (CDC, 2014a). For the age group from birth through 6 years, there are 15 diseases for which vaccines are recommended. To increase effectiveness, some vaccines need to be given more than once. Combination vaccines are generally preferred over separate injections of equivalent component vaccines and should be based on parents’ preference, the potential for adverse events, an assessment of the number of injections needed, vaccine availability, the likelihood of improved coverage, and whether the patient will return for another vaccine (CDC, 2011a). Some vaccine combinations require different schedules than the monovalent November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PhotoEuphoria / iStockphoto
Acceptance of the importance of immunizations is at times hindered by a history of powerful biological, social, and cultural reactions from the public.
vaccine, which may be confusing when a child is treated by multiple healthcare providers. However, if the child has already received the recommended vaccinations for some of the components in a combination vaccine, administering the extra vaccines in the combination is acceptable. Although children from 7 to 18 years of age have less frequent well-child visits than younger children, protection from VPDs is still needed. Some of the protection from earlier vaccines may wane making children vulnerable to VPDs. If primary vaccination coverage is incomplete, there will be a resurgence of VPDs (Blendell & Fehr, 2012). Except for the annual influenza vaccines, schedules for children from 7 to 10 are primarily catch-up schedules. The health visit for 11- and 12-year-olds involves three recommended immunizations as well as the annual influenza vaccine. These vaccines include the tetanus, diphtheria, and accellular pertussis vaccine (Tdap), a vaccine to prevent meningitis (MCV4), and a vaccine to prevent Human papillomavirus (HPV). Regardless of whether the child received the entire DTaP series in early childhood, the Tdap is given as a booster for children over age 7. The Tdap is sometimes confused with the DTaP (Institute for Safe Medication Practices, 2010). If DTaP is given by mistake, the recipient may have a sore arm at the injection site. Should infants and small children receive the Tdap instead of the TDaP, they would be receiving a lower dose of the components than recommended. Because of recent outbreaks of pertussis in infants (3.8/1,000,000 live births in United States), the Tdap is strongly recommended for those adults who have close contact with infants under 12 months of age (Haberling, Holman, Paddock, & Murphy, 2009). Many healthcare providers believe that certain conditions such as a low-grade fever preclude children from receiving vaccinations (AAP, 2013). Other common conditions that are often perceived as contraindicated include diarrhea, minor upper respiratory illnesses with or without fever, otitis media, mild-to-moderate local reactions to a previous dose of vaccine, current antibiotic treatment, and convalescence from an acute illness (CDC, 2011a). With moderate-to-severe acute illnesses, vaccinations are deferred primarily to prevent diagnostic confusion between manifestations of illness and an adverse event. The only contraindication applicable to all vaccines is a history of a severe reaction to a previous November/December 2014
dose of the same vaccine or vaccine component. However, in most cases these individuals would benefit from protection with other vaccines (Shepherd & Grabenstein, 2001). Generally live attenuated vaccines such as the varicella zoster, and MMR are not recommended for individuals who are pregnant or immune-compromised.
Parental Concerns About Immunization Although most concerns about vaccine safety are expressed by parents of underimmunized children, parents who immunize their children also have concerns (Freed, Clark, Butchart, Singer, & Davis, 2010). Many parents believe that protection from infectious disease through immunization is common practice and are less concerned with the consequences of VPDs than any risks associated with vaccines. Newer vaccines such as HPV and meningococcal conjugate vaccines are more likely to be refused due to lack of trust (Freed et al., 2010). An understanding of why parents refuse to vaccinate their children could lead to better communication and less need for nonmedical exemptions. Concerns about the safety of vaccines are accentuated by the rapid speed by which information and misinformation about vaccines and vaccine-preventable diseases are spread via the Internet. Over the past several years, there have been many antivaccination activists on the World Wide Web (Davies, Chapman, & Leask, 2002). Web sites, blogs, social networks, and even YouTube add to the burgeoning misinformation about vaccinations. Simply promoting the use of vaccines is no longer effective as individuals and families try to make informed decisions amidst a maelstrom of conflicting messages. In a national survey of the prevalence of vaccine refusal and specific parental safety concerns, more than half of the parents (n = 1552) expressed concerns about serious adverse effects (Freed et al., 2010). Women were more likely to believe that some vaccines caused autism in healthy children and would refuse a recommended vaccine. Although Hispanic women were more likely than White or Black parents to believe that some vaccines were associated with autism, this group was more likely to follow the recommendations than were the other groups. Black parents, however, were more likely than White and Hispanic MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
353
Table 1. Resources for Providers and Parents Resources for Providers:
Type of resource/website
Safety of Vaccines Used for Routine Immunization in the United States, Agency for www.effectivehealthcare.ahrq.gov/reports/final.cfm Healthcare Research and Quality (Evidence Report/Technology Assessment No. 215) Vaccine Information Statements (VIS)
wwwt.cdc.gov/vaccines/pubs/vis/default.htm
Vaccine for Children Program
www.cdc.gov/vaccines/programs/vfc/index.html
Screening Checklist for Contraindications for Vaccines for Children and Teens
www.immunize.org/catg.d/p4060.pdf
Talking with parents about immunizations
www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html www.cdc.gov/vaccines/hcp/patient-ed/conversations/conv-materials.html
Form for documenting parental refusal of vaccination
http://www2.aap.org/immunization/pediatricians/pdf/refusaltovaccinate.pdf
Responding to common misconceptions about immunizations
www.cdc.gov/vaccines/vac-gen/6mishome.htm
Guide to vaccine contraindications and precautions
www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm
Vaccine Adverse Reporting Systems (VAERS)
www.vaers.hhs.gov/index
Vaccines for your children
www.cdc.gov/vaccines/parents/index.html
Parents’ frequently asked questions
http://www2.aap.org/immunization/families/faq/FAQ_Safety.pdf
Facts for parents about vaccine safety
http://www2.aap.org/advocacy/releases/autismparentfacts.htm
parents to refuse a recommended vaccine. Rationales for refusals by population groups were not identified. The most highly publicized challenge to immunization adherence is the association of the MMR vaccine with autism (Smith, 2010). More than one in five parents believe that some vaccines cause autism in otherwise healthy children (Freed et al., 2010). Despite evidence that the threat was unfounded, some continue to refuse the MMR. As a consequence, measles epidemics have erupted as the disease is carried into the country by immigrants and international travelers. In the first 3 months of 2014, 288 cases of measles were reported to the CDC (CDC Press Release, 2014b). This incidence is the largest reported since 1994. A lack of trust about vaccine safety continues to exist with other vaccines as well. Although the acellular pertussis component replaced the original pertussis component and eliminated most adverse events from the first DPT vaccinations, a lack of trust for this vaccine continues and outbreaks persist. In 2010, an outbreak of pertussis in California sickened 6,200 people and resulted in the death of 10 infants (California Department of Public Health, 2010). Some parents question the need for the Hepatitis B vaccine in infancy as they perceive the vaccine as primarily for those who engage in intravenous drug use and high-risk sexual behavior. The American Academy of Pediatrics (AAP, 2013) recommends that parents be advised that the vaccine ensures protection throughout 354
volume 39 |
number 6
life from a virus that often has no symptoms and can lead to premature liver diseases, cancer, and death. Despite recent influenza outbreaks, parents question the need for an annual influenza vaccine. Parents may not be aware that immunity to one strain of influenza does not provide protection against new strains of the virus. Some parents believe that chicken pox is a harmless childhood disease and are unaware of the associated sequela. Although the vaccine may not provide total immunity, it does prevent severe chickenpox in over 95% (AAP, 2013). When there is a lack of reliable information from healthcare providers and confusing information from the media, parents may elect a nonmedical exemption for their children. In states where policies for nonmedical exemptions are unrestrictive, parents may request an exemption based on inconvenience (Blank et al., 2013). Nurses have a vital role in decreasing nonmedical exemptions by influencing parents’ decisions about vaccinating their children. In a secondary data analysis from the National Immunization Parental Knowledge survey (2001–2002) of parents (n = 7695) of children 19 to 35 months, Smith, Kennedy, Wooten, Gust, and Pickering (2006) concluded that parents who believed that providers were influential in helping them make the decision to immunize their child were twice as likely to respond that vaccines were safe for children. Among those who believed that vaccines were not safe, respondents indicated that their decision to vaccinate was influenced by their healthcare provider. November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Improving Immunization Adherence As trusted healthcare providers, nurses are in a unique position to break down barriers to immunizations by addressing parental concerns about vaccine safety. Nurses need to examine their own attitudes and beliefs about immunizations to ensure that they are giving positive information to parents. A survey of knowledge, attitudes, and beliefs of school nurses and other school personnel revealed that children attending schools that had school nurses were significantly less likely to have an immunization exemption than those who attended a school without a school nurse (Salmon et al., 2004). Nurses were more likely than nonnurse school personnel to believe in the effectiveness and safety of vaccination. Nurses, who practice in a variety of settings, must use every encounter with parents to espouse the benefits of immunizations and dispel any myths. According to an innovative UNICEF working paper, there has been a rise in antivaccination sentiment in Europe indicating that parents are using social media networks to make decisions about immunizing their children (UNICEF, 2013). Nurses may influence parental decision about immunizations by responding to their concerns and directing them to Web sites that contain reliable information. Tips for selecting appropriate immunization Web sites can be accessed by going to www. immunizationinfo.org/parents/evaluating-information-web Building relationships with parents that inspire trust may be more important than the information provided (Leask et al., 2012). Open-ended questions and active listening should be used to assess parent’s concerns. Once concerns are addressed, nurses should update the immunization history and inquire about any past adverse events related to immunizations. Before administering immunizations, nurses should screen for contraindications or precautions to immunization. The Immunization Coalition provides an easily adaptable screening tool for contraindications and precautions (Table 1 of Resources). Prior to administering vaccines, nurses must give parents a written copy of the appropriate vaccine information statements (VIS) (CDC National Vaccine Program Office, 2013). The VIS contains the risks and benefits for each immunization. Copies of the VIS, in English, Spanish, and other languages, can be downloaded from the CDC Web site (Table 1 of Resources). Should an adverse event occur, nurses must report these events through the Vaccine Adverse Events Reporting System (VAERS), a national vaccine safety surveillance program for monitoring information about vaccine adverse events (Table 1 of Resources). One of the biggest challenges for nurses is financial and behavioral barriers to immunizations. Financial barriers may be related to expenses for vaccines and provider payment mechanisms. Through the Vaccines for Children program, eligible children can receive, free of charge, all recommended vaccines (Table 1 of Resources). Behavioral and attitudinal barriers are often more diffi cult to remove. Behavioral barriers may be related to cultural, religious, or personal beliefs about immunizations (AAP, 2013). Because every situation is unique, nurses need to determine parents’ positions on immuNovember/December 2014
nizations. Recently, Leask et al. (2012) identified five parental positions on vaccinations: unquestioning acceptor (30–40%), cautious acceptor (25–35%), hesitant (20–30%), late or selective vaccinator (2–27%), and refuser (≤2%). Approaches to parents should be based on parents’ readiness to vaccinate their children. For the hesitant, late or selective vaccinators, or refusers, nurses should use a guiding style that elicits the parent’s own motivations to vaccinate. At all times, the nurse should avoid confrontational approaches. Many parents believe that VPDs are not serious illnesses that warrant vaccination (Blendell & Fehr, 2012). Nurses can provide CDC data about rising rates of VPDs in the community with evidence that demonstrates vaccine safety. As trusted healthcare providers, nurses can influence parents’ decisions about immunizing their children and help to prevent disease outbreaks. Parents need information about the effect of disease outbreaks on their children’s ability to attend school. When an outbreak occurs, unvaccinated children are not permitted to attend school. Outbreaks tend to occur in waves, meaning that an unvaccinated child could miss several months of school (CDC National Vaccine Program Office, 2013). Despite evidence supporting the safety and efficacy of immunizations, nonmedical exemptions continue to rise (Blank et al., 2013). One approach to minimizing exemptions may be to require parents considering a nonmedical exemption to attend educational sessions given by nurses or other healthcare providers (Salmon, 2003). Blank et al. (2013) suggest that policy makers consider strengthening nonmedical exemption procedures and encouraging annual educational sessions for parents who refuse to immunize their children. Although nurses and other healthcare providers can guide parents’ decisions about immunizations, parents are ultimately responsible. If after careful discussion, parents still refuse immunizations for their children, nurses should document the reasons for refusing the immunizations and revisit the issue during future healthcare encounter. Outreach to ensure that parents are taking advantage of immunization opportunities is needed. Information about immunizations needs to include more than reminders about recommended appointments. Nontraditional approaches such as social marketing can be used to reach the public. Social marketing may increase vaccination rates by using commercial marketing techniques, behavior change theory, and social psychology to capture the public’s attention and motivate change (Opel, Diekema, Lee, & Marcuse, 2009). Because social marketing strategies appeal to emotion, this strategy may be an effective response to the antivaccination movement. California has used such a campaign and Washington is pursing a campaign to increase timely immunizations among children from birth to age 24 months.
Conclusions Even though VPDs are practically extinct in the United States, nurses need to help parents understand that the risk of the disease is still very real. More parents are refusing vaccines, and outbreaks of VPDs remain a problem. Given MCN
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
355
the various reasons for parental refusal of immunizations, a “one-size-fits-all approach” ignores the realities of how people are persuaded. Nurses can take the lead as active advocates for immunizations by recognizing parents’ positions on immunizations, building trust, and adapting educational materials in a way that effectively addresses their concerns. Many approaches to improving immunization adherence have been identified in the literature, yet evidence is needed to test approaches that are successful in decreasing nonmedical exemptions. Nurses can also proactively influence public policy about nonmedical exemptions. With the Affordable Care Act, more people will have access to immunizations. Public health workers, health insurers, and healthcare providers will need to work together to ensure immunization coverage. A comprehensive resource was published in July 1, 2014, by the Agency for Healthcare Research and Quality (AHRQ); Safety of Vaccines Used for Routine Immunization in the United States (Maglione et al., 2014). This AHRQ Evidence Report/Technology Assessment (Maglione et al., 2014) is highly recommended as a resource for healthcare providers to assist them in providing current, accurate, and thorough information about vaccines used for routine vaccination in the United States to parents. Although many resources about vaccines are available, information is not reaching parents in an effective or convincing way (Freed et al., 2010). The media often reports stories of individuals who developed a medical problem after being vaccinated. Yet, millions of children are vaccinated and protected against VPDs without any adverse events. Although these success stories may not be newsworthy, they are evidence of the success of immunizations. Support and encouragement by nurses to parents who are in the process of a decision about vaccination of their child that is based on accurate information can promote best practice and a healthy childhood outcome. ✜ Gail Holland Wade is an Associate Professor, School of Nursing, University of Delaware, Newark, DE. The author can be reached via e-mail at [email protected] The author declares no conflict of interest. DOI:10.1097/NMC.0000000000000083 References American Academy of Pediatrics. (2013). Addressing common concerns of vaccine-hesitant parents. Elk Grove Village, IL: Author. Retrieved June 27, 2014 from http://www2.aap.org/immunization/ pediatricians/pdf/vaccine-hesitant%20parent_final.pdf Blank, N. R., Caplan, A. L., & Constable, C. (2013). Exempting schoolchildren from immunizations: States with few barriers had highest rates of nonmedical exemptions. Health Affairs, 32(7), 1282-1290. doi:10.1377/hlthaff.2013.0239 Blendell, R. L., & Fehr, J. L. (2012). Discussing vaccination with concerned patients: an evidence-based resource for healthcare providers. Journal of Perinatal & Neonatal Nursing, 26(3), 230-241. doi:10.1097/JPN.0b013e3182611b7b California Department of Public Health. (2010). Pertussis report. Sacramento, CA: Author. Retrieved June 27, 2014 from www.cdph.ca.gov/ programs/immunize/Documents/PertussisReport2010-12-15.pdf CDC National Vaccine Program Office. (2013). Immunization laws. Retrieved from http://www.hhs.gov/nvpo/law.htm. 29 July 2013. Centers for Disease Control and Prevention. (2011a). General recommendations on immunization: Recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep, 60(2), 1-61. www.cdc.gov/mmwr/pdf/rr/rr6002.pdf
356
volume 39 |
number 6
Centers for Disease Control and Prevention. (2011b). Ten great public health achievements-United States, 2001-2010. MMWR Morb Mortal Wkly Rep, 60(19), 619-623. Retrieved June 27, 2014 from www. cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm Centers for Disease Control and Prevention. (2012). National, state, and local area vaccination coverage among children aged 19-35 monthsUnited States, 2011. MMWR Morb Mortal Wkly Rep, 61(35), 689-696. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6135a1.htm?s_ cid=mm6135a1_w Centers for Disease Control and Prevention. (2014a). Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older—United States, 2014. MMWR Morb Mortal Wkly Rep, 63(5), 110-112. Retrieved June 27, 2014 from www.cdc. gov/mmwr/preview/mmwrhtml/mm6305a7.htm?s_cid=mm6305a7_w Centers for Disease Control and Prevention. (2014b). Measles cases in the United States reach 20-year high (Press release May 29, 2014). Retrieved from www.cdc.gov/media/releases/2014/p0529-measles.html Davies, P., Chapman, S., & Leask, J. (2002). Antivaccination activists on the world wide web. Archives of Disease in Childhood, 87(1), 22-25. Freed, G. L., Clark, S. J., Butchart, A. T., Singer, D. C., & Davis, M. M. (2010). Parental vaccine safety concerns in 2009. Pediatrics, 125(4), 654-659. doi:10.1542/peds.2009-1962 Haberling, D. L., Holman, R. C., Paddock, C. D., & Murphy, T. V. (2009). Infant and maternal risk factors for pertussis-related infant mortality in the United States, 1999 to 2004. Pediatric Infectious Disease Journal, 28(3), 194-198. doi:10.1097/INF.0b013e31818c9032 Institute for Safe Medication Practices. (2010). DTaP –Tdap Mix-ups now affecting hundreds of patients (ISMP Medication Safety Alert). Retrieved from www.ismp.org/newsletters/acutecare/articles/20100701.asp Leask, J., Kinnersley, P., Jackson, C., Cheater, F., Bedford, H., & Rowles, G. (2012). Communicating with parents about vaccination: A framework for health professionals. BMC Pediatrics, 12, 154, doi:10.1186/1471-2431-12-154 Maglione, M. A., Gidengil, C., Das, L., Raaen, L., Smith, A., Chari, R., . . ., Goetz, M. B. (2014). Safety of Vaccines Used for Routine Immunization in the United States (Evidence Report/Technology Assessment No. 215). (Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 14-E002-EF. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from www.effectivehealthcare.ahrq.gov/reports/final.cfm National Vaccine Information Center. (2014). Vaccine laws. Retrieved from www.nvic.org/vaccine-laws.aspx Omer, S. B., Richards, J. L., Ward, M., & Bednarczyk, R. A. (2012). Vaccination policies and rates of exemption from immunization, 2005-2011. New England Journal of Medicine, 367(12), 1170-1171. doi:10.1056/NEJMc1208306 Opel, D. J., Diekema, D. S., Lee, N. R., & Marcuse, E. K. (2009). Social marketing as a strategy to increase immunization rates. Archives of Pediatrics and Adolescent Medicine, 163(5), 432-437. doi:10.1001/archpediatrics.2009.42 Salmon, D. A. (2003). Mandatory immunization laws and the role of medical, religious and philosophical exemptions. Unpublished commentary, Institute for Vaccine Safety Disease Prevention and control – Department of International Health Johns Hopkins Bloomberg School of Public Health. Salmon, D. A., Moulton, L. H., Omer, S. B., Chace, L. M., Klassen, A., Talebian, P., & Halsey, N. A. (2004). Knowledge, attitudes, and beliefs of school nurses and personnel and associations with nonmedical immunization exemptions. Pediatrics, 113(6), e552-e559. doi:10.1542/peds.113.6.e552 Shepherd, J. E., & Grabenstein, J. D. (2001). Immunizations for high-risk populations. Journal of American Pharmacy Association, 41(6), 839-849. Smith, M. J. (2010). Parental vaccine refusal. Contemporary Pediatrics, 27(2), 36-47. Smith, P. J., Kennedy, A. M., Wooten, K., Gust, D. A., & Pickering, L. K. (2006). Association between health care providers’ influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics, 118(5), e1287-e1292. doi:10.1542/peds.2006-0923 Stern, A. M., & Markel, H. (2005). The history of vaccines and immunization: Familiar patterns, new challenges. Health Affairs, 24(3), 611621. doi:10.1377/hlthaff.24.3.611 UNICEF. (2013). Tracking anti-vaccination sentiment in Eastern European social media networks. Retrieved June 27, 2014 from www. unicef.org/ceecis/media_24017.html United States Department of Health & Human Services. (2013). Healthy People 2020 Topics & Objectives: Immunization and infectious diseases. Retrieved June 27, 2012 from www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=23 Welborn, A. (2005). Mandatory vaccinations: Precedent and current laws. Congressional Research Service: Report for Congress. Report No. RS21414. Retrieved June 27, 2014 from www.infowars.com/ mandatory-vaccinations-precedent-and-current-laws/ November/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
