Vaccine Refusal

Basics

A decision by a patient or parent to delay or refuse a vaccine recommended by a health care provider
Comprises a range of behaviors from unquestioning acceptance of vaccines to cautious or selective acceptance to refusal of all vaccines
Influenced by the interaction of several factors related to: confidence, complacency, and convenience
- Confidence: lack of trust in vaccines, health care providers, and/or health care system
- Complacency: low prioritization of vaccination related to low perceived risk of vaccine preventable diseases
- Convenience: barriers to accessing immunization services (e.g., vaccine cost or difficulty getting to immunization provider)

Majority of adults in the United States believe vaccination is extremely or very important, but increasing proportion believe vaccines are more dangerous than diseases they prevent.
Majority of pediatricians report >1 vaccine refusal/month.
>1/3 of pediatricians will accept requests to delay certain vaccines, but fewer than 10% agree with such requests.
Among a cohort of undervaccinated young children, 13% were undervaccinated due to parental choice.
Rate of infants who receive first vaccine dose at age 4 to 5 months increased from ~50/10,000 to 100/10,000 across five successive birth cohorts (2004 to 2008).
In the 2015 to 2016 school year, exemption rates for kindergarten school entry requirements rose from 0.4% to 6.2% across U.S. states.

Because of the heterogeneity of vaccine hesitancy, there is no one singular set of risk factors. However, contributors to refusal include:

Less experience with vaccine preventable diseases due to decreased disease incidence. This leads to underappreciation of disease risk and severity and parents may question need for vaccines.
Vaccine safety concerns—especially as concerns about risk of vaccine—preventable diseases decreases, parents may worry more about potential risks of vaccination.
Rapid dissemination of information increases likelihood of access to misinformation about vaccines, which may reinforce vaccine safety concerns,
Anti-vaccine advocacy by prominent public figures that call attention to anti-vaccine beliefs.
Increase in scientific denialism, which is rejection of facts for which there is well-established scientific consensus.

Early communication about vaccines with parents can help identify and address concerns to prevent vaccine refusal or delay.
Opportunities may include prenatal visits, in the nursery prior to discharge from the hospital after or at the newborn visit.

For some parents, vaccine refusal may be associated with refusal of other health care interventions.
Some parents may accept all recommended vaccines but request an alternative schedule. Alternative vaccine schedules spread out the recommended vaccine doses, resulting in immunization delay for some vaccines.
Reasons for request of alternative vaccine schedules:
- Belief that receiving multiple injections at same time overwhelms the immune system
- Belief that recommended schedule exposes infants to too much aluminum

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