The Measles Makes a Comeback

This year saw the largest outbreak of measles in the U.S. since 1994, with 1,250 cases reported as of October 3, largely driven by families choosing not to vaccinate their children. Worldwide, the disease has resurfaced in areas that had been declared measles-free.

So now, measles ― the most contagious of vaccine-preventable illnesses ― has become a national epidemic and growing health concern. Why? Because parental behavior regarding immunizations has begun to change the statistics.

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Pediatric studies have shown an increase in vaccine refusal. Parents who decline vaccinations for their children believe that immunizations are unnecessary. Multiple sources have taken a different stance and challenged the scientific research that has stood for decades. With various degrees of information available, some find it difficult to determine what is a legitimate source.

What can physicians do to help educate and quell the fears of the parents and patients when discussing vaccinations?

There are three groups of patient-parents: 1) the compliant group — those who follow the guidelines and seek out vaccinations; 2) the noncompliant group – those who are adamantly anti-vaccine (there is very little, if any, way to engage this group into getting the recommended vaccines); and 3) those who are vaccine-hesitant. This last group is the one to spend more time with, educating them on the risks and benefits of vaccination. They may have been the parents who heard something on TV or came across something on the Internet and are not sure whom or what to believe. Taking a bit more time with them, explaining the facts and science of vaccinations, may more likely lead them to choose vaccination for their children.

There are a variety of approaches to education you may take. For example, consider providing a list of trusted sources of vaccine information from various websites. The ones noted at the end of this article provide literature and videos in several languages to assist in the educational process.

Another approach involves sharing examples from your personal experience. Chapman University Professor Jeff Goad, Pharm. D., recommends “personalizing” stories rather than stating statistics. This is the practice used by pediatrician Ruben J. Rucoba, MD. “I spoke of the measles epidemic I witnessed as an intern in 1989 during my first rotation on the infectious diseases floor. I told them about a young boy who came in with the measles, deteriorated, and ultimately died. I related the story to another patient who entered the hospital as an energetic, playful toddler, but left neurologically devastated and dependent on a tracheostomy and G-tube feedings.”

What to Do When Parents Refuse Vaccinations

What if, despite your best efforts, the patient-parent refuses vaccinations for his or her child? A growing number of pediatricians continue to provide vaccine education but are also dismissing patients at higher rates. But first, listen carefully and respectfully to the parents as to their concerns, worries, and questions. Reasons for refusal may be due the cost of the vaccines, concern about the child’s discomfort from multiple vaccine administrations at a single visit, or fear that too many vaccines may be harmful for their child’s immune system.

While there is not a 100 percent risk-free guarantee or effective rate, the physician should share what is and is not known about the risks and benefits of the vaccine in question, attempt to understand the parents' concerns about immunization, and attempt to correct any misconceptions and misinformation. All discussions, including education, benefits of immunization, and risks associated with remaining unimmunized, should be thoroughly documented in the medical record.

Physicians may also consider having the parent sign a “Refusal to Vaccinate” wavier. Vaccine exemption forms should only be signed if there is medically-justified contraindication to the child’s health with thorough documentation in the medical record. (Refer to California State Senate Bill 276 for guidelines.)

Although the Academy of Pediatrics does not endorse patient dismissal, it is ultimately the physician’s choice. Choosing dismissal or declining a new patient as an option for anti-vaccine patients can be the policy of your office. If the family does not have faith and trust in their caregiver on the issue of vaccinations, that may also weaken the physician-patient relationship if more complicated medical situations arise. Prior to establishing the physician-patient relationship, have a “pre-meeting” or “get-to-know-you” appointment to discuss your practice philosophy and set patient-parent expectations to determine if this will be a mutually beneficial relationship.  



Refusal to Vaccinate Form
Discontinuing Patient from Practice Guidelines/Sample Letter

Educational Websites:

American Academy of Pediatrics

Vaccine Information

Centers for Disease Control

Every Child by Two

World Health Organization

National Foundation for Infectious Diseases


Deborah Kichler is a Senior Risk Manager for CAP. Questions or comments related to this article should be directed to