Vaccine Refusal



  • 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.

Risk Factors

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.

General Prevention

  • 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.

Commonly Associated Conditions

  • 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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