Exemption requests typically fall into three categories: medical, religious, and philosophical. It is important for the otolaryngologist in this scenario to ascertain the basis for the parents’ concerns and address them as professionally appropriate. Typically, parental concerns regarding vaccinations tend to rest on the possible adverse effects of vaccines on the child’s developing immune system; the “overwhelming” dosage of combination vaccinations; the presence of additives, such as thimerosal, that have been used in some vaccines; and occasionally, financial constraints and lack of access to healthcare resources.
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October 2017Otolaryngologists are not tasked with the actual responsibility of immunizing children; however, the fact that vaccines currently in clinical use have greatly reduced the severity of many diseases common to the history of this specialty means that otolaryngologists do have a stake in the discussion.
Explain Herd Immunity
The otolaryngologist should determine the parents’ knowledge base about the science of vaccinations and their importance in public health. In the minds of the parents of a young child, even the rarest side effects of a vaccine can become a serious concern. It would be helpful at the start to review for them how many millions of lives over the past century have been saved because of vaccines, along with the serious nature of the diseases they prevent or lessen in intensity. The otolaryngologist can describe the serious diseases she has seen or learned about over the course of her career that have been curtailed, mitigated, or prevented by microbe-specific vaccinations, and the suffering of children that has been greatly alleviated. Examples from one’s professional experience are often very powerful tools in such discussions.
The science of “herd immunity” should be explained to the parents in terms they can easily understand. In general, herd immunity occurs when a sufficient rate of immunity, through vaccinations, is achieved within the community to greatly reduce the risk of infection in not only those immunized but especially in those persons who have not been immunized. Each infectious disease entity has its own threshold of immunization rate for producing herd immunity, based in part on its basic reproduction factor (contagiousness).
An informative exercise for the otolaryngologist, as well as the parents, is to access the NIH Disease Transmission Simulation site, which, given a certain infectious disease, can show how the rate of infection can vary with the percent of community immunization (available at science.education.nih.gov. If one were to use the following data in the simulator for a measles outbreak in a community—0.1 virulence rate (likelihood of dying from the infection), 10-day duration of infection, 9.0 rate of transmission—and observe the resultant spread of disease through the community population comparing 70%, 80%, and 90% initial immunity rate, it is obvious that 90% herd immunity would be required to reduce the spread of disease below the level of an “epidemic.” This is very convincing, graphic evidence.
Addressing Hesitancy
Vaccine hesitancy is very complex and is dependent upon the context of the particular family perspective and health status. Primary factors in hesitancy are misunderstanding and misinterpretation of the science of vaccines, as well as misconceptions furthered by social media and unsubstantiated “reports.” For example, it is agreed in the legitimate scientific community that rigorous meta-analyses of available data do not support vaccinations as a cause of autism—yet parental concerns persist. It is true that vaccines are not without risks; however, the risks are very rare, and vaccines are heavily regulated by the appropriate federal agencies to comply with high safety standards. Substantial risks are quickly investigated, and action is taken to identify the potential problem, and is followed by appropriate remediation.