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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000407297.10524.9e
AJN Reports

Childhood Vaccinations

Nelson, Roxanne BSN, RN

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Mistrust lingers despite encouraging data.

In 1998 British physician and researcher Andrew Wakefield and his colleagues published in the Lancet the results of a small study that raised the possibility of associations between gastrointestinal disease, autism, and the measles–mumps–rubella (MMR) vaccine. The report was immediately controversial, and even though critics pointed out its limitations, it nevertheless triggered a worldwide scare that led to a decline in immunization rates. A number of studies have examined the possible link between the MMR vaccine and autism, and none has ever been found. The report itself has since been retracted by the Lancet and Wakefield was discredited as evidence revealed a confusion of falsified data, conflicts of interest, and greed. Nevertheless, the autism-vaccine debate has continued. (For details, see the series of articles by journalist Brian Deer in BMJ, which was introduced in an editorial:

Figure. British phys...
Figure. British phys...
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Criticism of vaccines isn't new, however, according to Mary Beth Koslap-Petraco, DNP, PNP-BC, CPNP, who told AJN that disputes over the morality, ethics, effectiveness, or safety involved go back to the days of Edward Jenner and the smallpox vaccine in the late 18th century. "It's an underlying fear of something that people may not have 100% faith in," she said.

The reticence still seen in many parents today likely has a number of causes. Certainly, one is that parents living in the United States have little or no fear of vaccine-preventable diseases. "They're more afraid of the vaccines than the diseases—because they have no experience with these diseases," said Koslap-Petraco, past chairperson of the National Association of Pediatric Nurse Practitioners (NAP-NAP) Immunization Special Interest Group and a past member of the National Vaccine Advisory Committee. "We don't have those kinds of threats now."

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Although vaccination is considered by many to be one of the greatest public health interventions of all time, there appears to be an increasing mistrust of vaccines worldwide, particularly in developing countries. According to Eliza Barclay, writing for National Public Radio's health blog, Shots (, a 2008 initiative in Ukraine that sought to vaccinate 7.5 million people against measles and rubella ended up reaching only 116,000 people. The vaccine campaign was suspended as a result of public mistrust of the vaccine.

Antivaccination groups have been active for years in both the United States and Europe. The MMR vaccine has been one of the most prominent targets, despite the lack of evidence linking it to autism.

"Wakefield has been refuted, and many people are aware of that, but it still lingers," said Ann Taub, RN, CPNP, of Baldwin Harbor Pediatrics in Queens, New York, and a cochairwoman of the NAPNAP Immunization Special Interest Group. She believes that the mainstream media are partly to blame for this. "The media like to use this old topic to stir up new stories, and this causes more confusion."

All vaccines can have adverse effects, Taub added, and new parents have a lot of anxiety. "We now know that autism is caused by genetic and environmental factors coming together, but we still don't have all the answers," she said. "Parents may get a false sense of control by refusing the vaccine."

According to a report from the National Committee for Quality Assurance (, compiling Centers for Disease Control and Prevention (CDC) statistics, in 2007 almost a quarter of children between the ages of 19 and 35 months hadn't received the recommended immunizations. Some data also indicate that childhood vaccine rates have declined, although it's unclear whether the trend will continue. Rates of MMR immunizations dropped from 93.5% in 2008 to 90.6% in 2009, rates of vaccination against diphtheria, tetanus, and whooping cough dropped from 87.2% in 2008 to 85.4% in 2009, and varicella immunizations declined from 92% in 2008 to 90.6% in 2009.

The decline in MMR vaccinations is of particular concern because the measles virus is highly contagious. In 2000 the United States announced the end of endemic measles transmission, and only 56 cases per year (on average) were reported between 2001 and 2008. Those cases primarily stemmed from people who were infected overseas and transmitted the virus to unvaccinated people in the United States. However, the number of cases jumped this year, coinciding with a large measles outbreak in Europe. According to statistics posted by the CDC in June, as of May there had been more than 10,000 cases and four deaths in the European Economic Area, with the bulk of cases seen in France, where more than 7,500 cases were reported from January through March, about the same number that occurred in all of 2010. In this same time period, 150 cases were reported in the United States, and although that number isn't exceptionally high, it's more than twice what would be expected in an entire year.

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Despite the reports of declining vaccination rates and efforts by antivaccination groups, most parents in the United States do adhere to the vaccination schedule.

"The vast majority of parents follow the schedule recommended by the Advisory Committee on Immunization Practices, the CDC, and the American Academy of Pediatrics," said Alison M. Buttenheim, PhD, MBA, assistant professor of family and community health at the University of Pennsylvania School of Nursing. "For example, in California, only 2.3% of entering kindergarteners in the fall of 2010 had a 'personal belief exemption' for one or more of the state-mandated vaccines. What's more common is parents requesting a tailored schedule that spaces vaccinations out over several visits or delays the administration of certain vaccines until a child is ready to enter school."

The children are usually up to date by kindergarten, she said, "but may have missed important months of coverage for diseases like measles or pertussis or rotavirus when they were young."

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Celebrities give antivaccination messages an identity, and celebrities do have influence, according to Taub. But studies show that the health care provider is more influential. "Providers need to emphasize that they're the ones who care for the child," she said. "And parents want clear, unbiased, accurate information about vaccines and vaccine safety. They want to feel that they have a relationship with you and that you care about their child."

Parents also do a lot of research on their own, looking to the popular press and to the Internet for information. "Parents want to bring concerns or questions raised during their research to the providers and have time for a real conversation about risks and benefits," said Buttenheim.

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There are many opportunities for nurses to influence decisions about vaccination, contends Buttenheim. "It starts in the hospital, when newborns normally receive their first vaccine, hepatitis B." Nurses working with new parents can help explain the importance of vaccines, support them through that first shot, and set them up for a positive view of vaccination, she said.

School-based nurses, too, have an enormous influence on vaccination rates and exemptions within the student population. "We've heard anecdotes about school nurses who are less tolerant of exemptions and refusals and can create a climate and culture that nudges reluctant parents toward vaccination," Buttenheim said.

Some pediatric practices are refusing to accept patients who aren't vaccinated, which Koslap-Petraco believes to be counterproductive. "We shouldn't shut them out of the practice," she said. "If we don't keep the channels open, there's no chance of continuing a dialogue or educating the parent."—Roxanne Nelson, BSN, RN

© 2011 Lippincott Williams & Wilkins, Inc.