The Anti-Vaxxers: Do You Discharge Them? Should You?

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Vaccine hesitancy is on the rise again. On average about 3% of parents refuse all vaccination for their children. Many more want to vary the recommenced schedule by “spreading” them out to avoid “overwhelming” the immune system, as they describe it.

Pediatricians struggle with what to do with families who refuse our advice to vaccinate their children. Until recently the American Academy of Pediatrics considered (AAP) it inappropriate for pediatricians to discharge such families from their care. That stance changed in an official statement from the AAP this August stating that physicians can dismiss nonvaccinating families, but only as a last resort.

Good arguments exist on both sides. Most pediatricians feel so strongly about vaccines that some consider not vaccinating a child as a form of child abuse. Yet, these same pediatricians who then refuse to care for the family that does not vaccinate would never discharge a family because a parent physically abused their child. They would want to help that family in crisis.

On do-ers and don't-ers

Pediatricians who discharge nonvaccinating families for refusing the MMR vaccine out of concern for other patients in their waiting room, healthy and immunocompromised alike, usually do not terminate families who refuse the flu shot. Yet, influenza can be deadly to both healthy and unhealthy children. Many more Americans (mostly adults) die from influenza every year than died from measles in the prevaccine era.

Pediatricians who “fire” families from their practice over nonvaccination argue that if a mother won't listen to them about vaccines, then she won't follow their advice about anything. At the same time, they do not discharge a family whose mother smokes around her asthmatic child against their advice, or the mother who is found feeding her overweight child potato chips and a soda when the pediatrician enters the exam room.

Pediatricians who do not fire families for noncompliance with the practice's recommended vaccine schedule argue that many parents will eventually develop a deeper trust of the pediatrician and his/her recommendations and eventually agree to have their children vaccinated. I think this happens, but in my experience it is uncommon. I would say that less than one in 20 sets of parents opposed to vaccines in general will ever change their minds. When a pediatrician does discharge a family, the family often ends up with providers who do not follow lots of other guidelines, leading to suboptimal care. I know this is a generalization, but in my own community it is true much more often than not. It is hard to disagree with the statement that all children need good pediatric care regardless of their parents' stance on vaccination.

Blame it on the state

My comments might make you think that I take the side of clinicians who feel noncompliant families should not be discharged, but I actually do discharge patients who do not meet my state's (North Carolina) daycare requirements. An MMR and varicella vaccine have to be given by 16 months, 3 doses of DTaP and Prevnar by 7 months. Polio, HIB, and hepatitis B are the other required vaccines. If a parent is willing to attempt to get caught up on vaccines, we will work out a mutually agreeable schedule, but not one that involves any significant delays. Using the state's requirements, in my opinion, makes our stance more understandable for most families and to a degree shifts the onus to the state and off of our small practice.

"My personal reasons for refusing..."

[[{"type":"media","view_mode":"media_crop","fid":"52676","attributes":{"alt":"©Dayna More/Shutterstock.com ","class":"media-image media-image-right","id":"media_crop_5247340326466","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6542","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 189px; width: 250px; float: right;","title":" ","typeof":"foaf:Image"}}]]What are my personal reasons for refusing to care for unvaccinated children? All of the preceding arguments are factors. I have 2 more that are perhaps a little selfish on my part. The norm in my locale is for children to get fully vaccinated. When I discuss our vaccine policy at a prenatal meeting, many parents voice their approval for this policy. From a purely business perspective, I think our stance on non-vaxxers provides more benefits to us in the long run than “losing” a  few families to other practices that tolerate a nontraditional vaccine policy.

The other “selfish” reason relates to how do deal after hours with the febrile child under 24- months of age. The approach to a 103°F-13-month-old is very different between a fully vaccinated child and one who is not: blood work for sure and maybe a spinal tap. Having practiced medicine before the HIB and Prevnar vaccines were available, I would not feel comfortable not seeing or not sending to the ED an unvaccinated, febrile child after that after-hours call from an anxious parent. The whole scene creates an anxious pediatrician:  me.

Will I remember to ask the parent during the 2-am call, “Is your child fully vaccinated?” when 99% of the time they are? What will a jury think about a pediatrician who tells a parent to bring their sick child into the office the following morning and that child turns out to have meningitis? Did that 10-hour delay in diagnosis lead to the hearing loss, seizure disorder, and mental retardation that resulted from the meningitis? You will be asked that question on the witness stand. If when you question the mom on the late-night call you don't think the child sounds too sick and you suggest a next day appointment, you may want to ask yourself what Clint Eastwood's Dirty Harry character once asked, “Well, do you feel lucky? Do you...?”

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