Review ArticlePractice

Addressing vaccine hesitancy

Clinical guidance for primary care physicians working with parents

Shixin (Cindy) Shen and Vinita Dubey
Canadian Family Physician March 2019, 65 (3) 175-181;

Article Figures & Data

Tables

  • Table 1.

    Sample statements for use by providers during vaccination-related conversations

    APPROACHSAMPLE STATEMENTS
    Start the conversation on vaccination using a presumptive approach31,32“Today we are going to give your child the recommended vaccines to keep the child healthy”
    “Your child needs 3 vaccines today” (instead of “What do you want to do about the shots?”)
    If parents are still unsure, continue the conversation on vaccination, address concerns, and make a strong recommendation32“I strongly recommend your child receive these vaccines today”
    “These shots are very important for protecting your child from serious diseases”
    Describe benefits of vaccines33“Vaccines work. Serious diseases can occur if your child is not immunized”
    Describe side effects25,31“There is a risk with vaccines just as with everything we do in life, like driving a car or riding a bike”
    “The risk of anaphylaxis after vaccination is approximately 1 in a million, the same as the yearly risk of being struck by lightning”
  • Table 2.

    Answers to questions commonly asked by parents

    QUESTIONSAMPLE ANSWER
    Benefits of vaccines
      • “Can my child still get a disease even after being vaccinated?”34,35“This is not very common. More than 95% to 99% of children develop immunity after vaccination, which further improves with boosters.33 Vaccinated children often get milder symptoms even if they do get the disease”
      • “Do we still need to give vaccines, as many of the diseases are no longer here?”34“Your child might never need the protection offered by vaccines, but you do not want her or him to be lacking the protection needed in the event of an outbreak, which still happens in Canada for diseases such as measles, mumps, and whooping cough. Vaccination is similar to wearing a seat belt; you do not expect to be in a collision, but in the unlikely event that you are in one, you want to be protected. Even if right now your child is able to avoid infectious diseases as everyone around is vaccinated, what if she or he decide to work elsewhere in the world later in life?31 Even if your child never travels internationally, others in your community travel and can bring back diseases”36,37
    Safety of vaccines
      • “How do we know vaccines are safe?”25,38“The safety of each vaccine is carefully checked before it is licensed and it is monitored on an ongoing basis after licensing. If a serious side effect is found, the vaccine is pulled from the market. I understand you might be concerned, but I truly believe that the risk of diseases is greater than any risk posed by vaccines”39,40
      • “How do we know vaccines do not cause long-term health problems?”34,40“Based on more than 50 years of experience with vaccines, it is not likely that vaccines cause unexpected long-term problems. Studies have found no relationship between vaccination and development of chronic diseases”25
      • “Can my child get a disease from the vaccine itself?”34,41“Inactivated or killed vaccines, which make up most vaccines, cannot give you the disease from the vaccine itself. Live vaccines contain viruses that are weakened, so occasionally you might get a mild case of disease (for example, a few spots of what look like chickenpox or measles). This is not harmful and actually means that the vaccine is working”
      • “Aren’t the ingredients in vaccines toxic?”34“Some ingredients in vaccines might be toxic, but only at much higher doses. Remember, even water can be toxic at high enough doses. The ingredients in vaccines are there to keep them from getting contaminated by bacteria and to make them work better”
      • “Why is aluminum in vaccines?”38“Aluminum is used to boost the immune system.34 It is commonly ingested from food, drinking water, and medicine. In fact, the amount of aluminum found in a vaccine is similar to the amount present in breast milk and infant formula”38
      • “Why is formaldehyde in vaccines?”38“Formaldehyde is used as a preservative. It is found naturally in foods.42 In fact, more formaldehyde is present in a pear than in all the vaccines a child receives”31
      • “Should I be concerned about mercury in vaccines?”42“Thimerosal is a form of mercury different from naturally occurring mercury like what is found in fish and cannot build up in a person’s body. Multiple studies have shown that thimerosal in vaccines is not harmful. It is no longer found in any routine childhood vaccines.25 It is only used as a preservative in certain influenza vaccines to prevent contamination”
      • “Doesn’t the MMR vaccine cause autism?”38,39,41“We all want answers to the cause of autism, including me. But study after study has shown that vaccines do not cause autism.43 One study showed that the rates of autism were the same in groups of children who received the vaccine compared with those who did not receive the vaccine”
    Immunity related
      • “Isn’t vaccination unnatural?”34“No, vaccines invite the immune system to produce its own protection, just like a natural infection would.31 The difference is your child does not have to get sick first to develop these protective antibodies”
      • “Isn’t natural immunity better than vaccination?”36,42“Although natural immunity might give better immunity than vaccines do, the risks are much higher. With natural infections, a child might develop complications such as permanent brain damage, deafness, blindness, and death. On the other hand, if your child is exposed to a disease after being vaccinated, he or she would already be armed and able to fight it off”35
      • “Can’t so many vaccines overwhelm my child’s immune system?”25,34,42“A child’s immune system has to deal with thousands of germs on a daily basis starting at birth. Scientists estimate that babies can handle up to 10 000 shots at one time.25 By stimulating the immune system to do what it is naturally meant to do, vaccines make your child’s immune system better at fighting off these diseases”38

    • MMR—measles-mumps-rubella.

  • Table 3.

    Selected resources on vaccination for health care providers and parents

    SOURCE, YEAR LAST MODIFIEDRESOURCEWEB ADDRESS*
    For health care providers
      • Public Health Agency of Canada, 2018cCanadian Immunization Guide1www.canada.ca/en/public-health/services/canadian-immunization-guide.html
      • NACI, 2018NACI recommendations, statements, and updateswww.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci.html
      • Canadian Paediatric Society, 2017Canada’s eight-component vaccine safety system: a primer for healthcare workers44www.cps.ca/en/documents/position/vaccine-safety-system
      • Canadian Medical Protective Association, 2017Duties and responsibilities. Expectations of physicians in practice. How to address vaccine hesitancy and refusal by patients or their legal guardians45www.cmpa-acpm.ca/en/advice-publications/browse-articles/2017/how-to-address-vaccine-hesitancy-and-refusal-by-patients-or-their-legal-guardians
      • Immunization Action Coalition, 2018Unprotected People Reportswww.immunize.org/reports
    For parents
      • Public Health Agency of Canada, 2018A Parent’s Guide to Vaccination46www.canada.ca/content/dam/phac-aspc/documents/services/publications/healthy-living/parent-guide-vaccination/pgi-gpv-eng.pdf
      • Immunize Canada, 2017CANImmunize appwww.canimmunize.ca/en/home
      • Canadian Paediatric Society, 2016Choosing not to vaccinate your child?
    Know your risks and responsibilities47    		www.caringforkids.cps.ca/uploads/handout_images/CFK_tearsheet-ENG(post).pdf
      • Canadian Paediatric Society, 2015Your Child’s Best Shot. A Parent’s Guide to Vaccination. 4th ed48bookstore.cps.ca/stock/details/your-childs-best-shot-a-parents-guide-to-vaccination-4th-edition

    • NACI—National Advisory Committee on Immunization.

    • ↵* Links last accessed on January 24, 2019.

  • Table 4.

    Interventions to reduce the pain associated with vaccination

    TYPE OF INTERVENTIONSTRONGLY RECOMMENDED INTERVENTIONS
    ProceduralFor all children, no aspiration during intramuscular vaccine injections; inject the most painful vaccine last
    PhysicalFor children aged ≤ 2 y, breastfeed during vaccine injections. For children aged ≤ 1 mo, encourage skin-to-skin contact
    PositioningFor children aged ≤ 3 y, encourage holding during injections, and if holding is not used, encourage patting or rocking after injections. Encourage children > 3 y to sit up during injections
    PharmacologicFor children aged ≤ 12 y, consider topical anesthetics before injections. For those aged ≤ 2 y, consider sucrose or glucose solutions before injections
    ProcessEducate parents of children of all ages about pain management for vaccine injection before or on the day of vaccination. For children aged ≤ 10 y, parents should be present during vaccine injections

    • Data from Taddio et al.65

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Addressing vaccine hesitancy
Shixin (Cindy) Shen, Vinita Dubey
Canadian Family Physician Mar 2019, 65 (3) 175-181;
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