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Parents’ Refusal to Vaccinate their Children: An Increasing Social Phenomenon Which Threatens Public Health
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ScienceDirect Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91
LUMEN 2014
Parents' Refusal to Vaccinate Their Children: An Increasing Social Phenomenon Which Threatens Public Health Carmen Liliana Barbacariua,* a
PhD, Teaching Assistant, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, General practitioner,Individual Practice, Pacurari no. 6 Str.,Iasi, post code 700537, Romania
Abstract Over the last few years, many controversies related to immunization safety have arisen, leading to an increasing number of parents who refuse to vaccinate their children. This study investigated the reasons behind child immunization safety concerns and the parent’s sources of information. The anti-vaccination movement had a negative impact on parents’ immunization behaviour.The numerous controversies and statements surrounding immunization side effects caused an erosion of public trust in the efficiency and safety of vaccination programs. Whether vaccination is voluntary or compulsory, each option faces complex ethical challenges because humans depend on each other in infectious diseases matter. © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license © 2014 The Authors. Published by Elsevier Ltd. (http://creativecommons.org/licenses/by-nc-nd/3.0/). Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. Keywords: vaccines safety; concerns; refused; behaviour
1. Introduction Vaccines play an important role in reducing infection in a population because they are the main weapon in the fight against the common diseases that we once feared. Thanks to vaccination programs, smallpox has been eradicated and we rarely see children suffering from polio palsy, diphtheria complications, or death and brain damage from measles. For example, 1 in 200 polio infections leads to irreversible paralysis, and among those paralyzed, 5% to 10% die when their breathing muscles become immobilized; there is no cure for polio, it can only
* Corresponding author. Tel.: +40722583612. E-mail address: [email protected],
1877-0428 © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. doi:10.1016/j.sbspro.2014.08.165
Carmen Liliana Barbacariu / Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91
be prevented (World Health Organization, 2013). Diphtheria vaccinations have proved important because even with treatment, about 1 out of 10 diphtheria patients dies due to airway blockage, myocarditis, or severe pneumonia with respiratory failure. Unfortunately, “measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available. In 2012, there were 122,000 measles deaths globally—about 330 deaths every day” caused by complications associated with the disease (World Health Organization, 2014). Vaccines are used to prevent the development of serious diseases in a host and are made of weakened or killed forms of bacteria or viruses, their toxins, or one of their surface proteins. These active components (the antigens) included in vaccines induce the immune response in the host’s body without passing on the real diseases. Vaccines may also contain additional components, such as preservatives (phenoxyethanol, phenol and thiomersal used to prevent contamination with fungi or bacteria), additives (to maintain the vaccine’s effectiveness by keeping the antigen stable during storage), adjuvants (various aluminium salts to enhance the immune response to a vaccine), and traces of other components (egg proteins, yeast, cell culture fluids, antibiotics, or inactivating agents left over from the process used to produce the vaccine) (Bumboiu and Bocsan, 2005, p.39). The terms immunization and vaccination are often used interchangeably, but their meanings are not exactly the same. Vaccination represents the process through which a vaccine is deliberately administered to an individual so that his immune system can prepare to fight a future infection. Immunization refers to the process by which a person becomes immune to a disease, either through vaccination or by contracting and fighting the disease naturally (Bumboiu and Bocsan, 2005, p.32). “Optimal response to a vaccine depends on multiple factors, including the type of vaccine, the age of the recipient, and immune status of the recipient. Recommendations for the age at which vaccines are administered are influenced by age-specific risks for disease, age-specific risks for complications, age-specific responses to vaccination, and potential interference with the immune response by passively transferred maternal antibodies" (Centers for Disease Control and Prevention, 2011, p. 4). In Romania, The Ministry of Health, in collaboration with The National Institute of Health, The National Centre for Infectious Disease Control and Prevention, and the Romanian Society of Pediatrics (RSP), establish a recommended schedule, free of charge, to provide routine administration of vaccines to children within the National Immunization Program (NIP).The legal framework for the NIP is established by The Ministry of Health's law No. 422/2013, and the schedule is permanently upgraded according to the World Health Organization’s (WHO) general recommendations on immunization (RSP, 2012). The number of immunizations recommended for children in the first two years of life has increased over time. In Romania, the recommended immunization schedules for 2014 included free vaccinations for 10 infectious diseases: HB (hepatitis B), BCG (Bacille de Calmette et Guérin—a vaccine against tuberculosis), DTaP/DT (diphtheria-tetanus-acellularpertussis/diphtheria-tetanus), IPV (inactivated polio vaccine), Hib (Haemophilus influenzae type b), and MMR (measles-mumps-rubella). Simplifying immunization schedules by combining multiple vaccines into a single syringe has numerous positive effects. Reducing the number of injections leads to a lower level of trauma for the infant and higher rates of compliance with complex vaccination schedules (Marshall et al., 2007). When a critical percentage (90-95%) of a population is immunized against a contagious disease, spread of the disease is reduced and most members of the community are protected. Even those who are not eligible for certain vaccines (such as young infants, pregnant women, or immune-compromised individuals such as organ transplant recipients, cancer patients, AIDS patients) or whose immune systems do not respond sufficiently to vaccination, receive some protection. This phenomenon is known as community immunity or herd immunity and it provides protection to individuals who cannot develop immunity. This indirect measure of protection raises an important issue about individual and public values (Sheriff et al., 2012). When immunization rates fall below these thresholds (90-95%), the risk of infectious outbreaks increases (measles and pertussis outbreaks have been attributed to declining herd immunity) (Fine, Eames, and Heymann, 2011). No vaccine offers complete protection, and like any medical procedure it comes with risks, even if serious side effects are mostly rare. Concerns regarding the safety of vaccines have existed in Romania since the first smallpox immunization campaigns in the eighteenth century, when only mandatory vaccination could stop the epidemic (Triscas, 2013). Over time, the public's specific concerns have changed as new vaccines have been developed and a lot of research regarding the safety of vaccines has been conducted (CDC, 2011; WHO, 2013).
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There were three goals of this study: (a) to investigate the reasons behind immunization safety concerns; (b) to identify the parents’ sources of information and their knowledge about vaccines used to prevent infectious diseases; (c) to describe the main reasons parents changed their minds about delaying or refusing a vaccine for their child. 2. Method We performed a qualitative research study within an individual family medicine practice in Iasi on a sample of parents with at least one child younger than 4 years of age (n=350). The focus group discussions were conducted individually, face to face with the parents, during the last month of pregnancy and then at their home, during the baby’s health care visit, first at several days after being discharged from the hospital and again at 1 month of age. The protocol was semi-structured with open-ended questions, allowing parents to discuss all aspects of vaccination from benefits to side effects. Furthermore, the conversation was supplemented by written material about the risks and advantages of each vaccine and information regarding the vaccine-preventable infectious diseases. The average time of each health care visit was between 30 and 60 minutes, depending on the problems and expressed concerns. Vaccine counseling and communication had been a longitudinal issue, mainly in the group of parents that refused to vaccinate their children. According to Patients’ Rights Law (No. 46/21.01.2013), the parents (the legal tutors of a child) have the responsibility to inform from accredited sources about vaccination and give their informed consent regarding the administration of vaccines to their child. Under the principle of respect for the autonomy of persons, we obtained a valid consent from individuals before vaccination. The data were systematized and a qualitative thematic analysis was performed to explore factors that influenced parents' decisions to refuse vaccination. 3. Results 3.1 Characteristics of study sample Among the 350 children under 4 years old (born between 2010 and 2013), we identified 26 (7.4%) children (from 24 families) whose parents refused all (n=14 children unvaccinated) or some (n=12 under vaccinated) of the vaccinations within the NIP. Demographic characteristics of the 24 families who refused vaccination are shown in Table 1. Table 1. Demographic characteristics of 24 families refusing child vaccination Characteristics Parent age
Parent education Birth year
Number of children in family
24-30 30 – 35 35 – 40 High school University 2010 2011 2012 2013 1 2 3 4
No
%
14 24 6 8 40 2 5 13 6 14 9 1 2
29 58 13 17 83 8 19 50 23 53 35 4 8
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Most families were young (87% of parents were between 24 and 35 years old) and had only one child (15 out of 26 children, 58%). Nine families had two children (in two cases parents refused vaccination for both children). Two families had four children and one family had three children (all of them were vaccinated except the youngest one). The study group included socially privileged people with a high level of education. Most of the parents (83%, or 20 out of 24 families) refusing vaccination had academic studies, while parents in four families had graduated only high school. Comparing children based on their birth year (2010 to 2013), we found a progressive increase of vaccine refusal over time, with a peak in 2012 (13 refusals out of 84, 15%) and also a spike of complete refusals among the children born in the second half of 2013 (6 complete refusals out of 85, 7%) (see Figure 1).
DTaP-Hib-IPV booster +MMR refusal MMR refusal
100% 95%
90% 85%
complete refusal of vaccination
80%
fully vaccinated 2010
2011
2012
We also found an increased refusal of DTaP-Hib-IPV booster and MMR among parents with children born in 2011 and 2012, because they changed their mind, to ultimately refuse vaccination. Of those who had refused at least one vaccine, MMR was the most commonly refused (100%), followed by the DTaPIPV-Hib booster (6 out of 12, 50%).
2013
Fig. 1.Trend of vaccination refusal over the four year study in the target group
Assessment of the reasons for vaccination refusal implied detailed analyses for each specific concern in the parental decision-making process. 3.2 Specific vaccine-related concerns expressed by parents y All parents were worried that the increasing number of recommended vaccines for babies at such a young age would overload the immature immune system. In 3 out of the 14 families who completely refused vaccination, this was the motivation for delaying their children’s vaccinations beyond the age of 24 months when the immune system should be more robust. y The diseases have disappeared, so why still vaccinate? This question was mentioned by most of the parents who completely refused vaccination. Nowadays, parents with young children do not have personal experience with poliomyelitis, diphtheria, or other vaccine-preventable diseases. As a result, they perceive low potential health risks from getting these infectious diseases. y Vaccines do not protect against the infectious diseases, they are unnecessary and do not work. Parents who refused all vaccines for their children were convinced that the incidence of infectious diseases had declined decades before the introduction of vaccination and it was primarily due to better personal hygiene, improved sanitation, good nutrition, and generally improved quality of life. They were convinced that despite the mass immunization programs, fully vaccinated populations have experienced epidemics. Some parents described close friends' negative experiences with their vaccinated children who got the disease. y Perceived advantages of having a disease were claimed by all parents regarding the MMR vaccine. They considered that measles, mumps, and rubella are specific childhood diseases without serious complications and that children will gain long lasting immunity after naturally fighting the diseases, compared to specific vaccination. Despite the fact that most of the parents were frightened about their child getting poliomyelitis, three parents argued that infection with polio virus is asymptomatic in 90% of cases; therefore, they did not consider vaccination as being mandatory. All of the parents who completely refused vaccination thought that their children would be healthier
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without it. y Most of the concerns were related to vaccine safety, and this is an important issue to discuss. Every parent involved in the vaccination decision-making process was frightened due to the controversial information coming from doctors who reported thousands of serious adverse vaccine reactions each year, including hundreds of deaths and permanent disabilities. Parents have read about the compensations for vaccine injuries in the United States. Hundreds of persons who filed a claim were paid money by the National Vaccine Injury Compensation Program (VICP), secondary to the decision of the United States Court of Federal Claims (Court). There are serious fears in relation to toxic components in vaccines. Such fears include the beliefs that their additives/adjuvants (thiomersal, aluminium, and phenoxyethanol) induce brain injury, autism, and other developmental disorders and that cell culture fluids with foreign DNA (Deoxyribonucleic acid) are considered to be the cause of the “cancer epidemic” or even AIDS. Moreover, autoimmune diseases such as asthma and other allergic diseases, multiple sclerosis, and sudden death in children were thought to have been caused by vaccination. y Some parents refused to have their children vaccinated, not because they feared autism, but because they mistrusted drug companies, government ministers, public health officials, and health policies. This attitude was observed mainly in association with big scandals related to adverse reactions secondary to BCG administrated in 2012. The majority of vaccination refusals in this study group were in 2012 (13 out of 84 children, 15%). y There were some families who reported negative experiences with vaccination. In this group, there were two families, having two children each, who refused to vaccinate their younger child because their elder one experienced multiple episodes of wheezing associated with viral infections and atopic dermatitis, problems for which parents blamed the vaccines. Despite this precaution, the unvaccinated children expressed the same symptoms, which proved a hereditary predisposition toward developing certain hypersensitivity reactions rather than adverse reactions caused by vaccines. y Finally, 7 out of 24 families admitted that they used alternative therapies such as homeopathy or that they believed Hamer's Germanic New Medicine, a system of pseudo-medicine that purports to be able to cure cancer, (Hamer lost his practice license in 1986 for malpractice) and other alternative medicine (naturopathy, energy medicine, and acupuncture), choosing to refuse conventional vaccines for their babies. 3.3 Parents' sources of information involved in the vaccination decision-making process The decision parents face regarding child immunization is a complex one, founded on numerous sources of information available. In this focus group, 20 out of 24 parents (83%) refusing vaccination had academic studies. Despite the high level of education, their decisions were not always based on scientific evidence. The analysis revealed that the sources of information approach very different perspectives. The parents accessed information from traditional sources, such as public health officials and physicians opinions (often with conflicting information), to nontraditional sources, such as online parents forums; press articles; television shows such as Romania, I Love You - Vaccines: Myth and Truth (ProTv, aired on 9 June 2013); anti-vaccination blogs and websites such as http://bucovinaprofunda.wordpress.com/category/antivaccin; and anti-vaccination books (de Brouwer, 2011; Todea-Gross, 2012). 4. Discussion Over the last few years, many controversies related to immunization safety have arisen, leading to an increasing number of parents who refuse to vaccinate their children. Their refusal is influenced by underestimating the severity of possible complications following preventable diseases while overestimating the vaccines’ side effects (Gust et al., 2004; Gust, Darling, Kennedy, & Schwartz, 2008). Our results reflected a decrease in vaccination coverage, a tendency also observed in the statistics reports of the Romanian National Centre for Infectious Disease Control and Prevention (CNSCBT, 2013). Vaccine coverage reported in clusters of babies born between 2008 and 2011 revealed a decrease from over 95% in 2008 to around 80% in 2011 (Table 2). The vaccination refusal percent had risen from 22.4% for those born in 2009 to 33.2% for those born in 2011, with higher rates of refusal in the urban area (CNSCBT, 2010-2013).
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Carmen Liliana Barbacariu / Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91 Table 2. Romania’s vaccination coverage reports from CNSCBT on 2010 – 2013 clusters of 2-year-old children Vaccine type
Vaccine coverage at 24 months (%) Born July 2008 Born July 2009
Born July 2010
Born July 2011
BCG 1
98.7
92.6
85.4
85.8
HB 3 doses DTaP booster IPV booster Hib booster MMR 1
97.7 95 95 96.5
90.5 87.4 87.4 88.6
83.5 81.1 81.0 81.0 82.0
83.6 79.8 79.7 79.7 81.7
Vaccination remains an emotional issue for many parents and general practitioners due to ethical crises that often arise. The “four principles” approach postulated by Tom Beauchamp and James Childress in their 2009 textbook, Principles of Biomedical Ethics must be taken into account while trying to find the best solution for ethical dilemmas (Gillon, 1994). Under the principle of autonomy, parents have the right to refuse vaccination for their children, a decision which is best made after being properly informed by accredited sources. Since vaccination is a preventative measure and not a treatment for a particular disease, the "first, do no harm" principle must guide all actions for the child’s best interest, also respecting the principle of beneficence. Vaccination refusal was found to rely on multiple factors including cultural, emotional, religious, and social issues. As in many other countries, in Romania there is a constant debate regarding paediatric vaccination policies between two distinct coalitions: those in favour of vaccination within NIP and those expressing concerns about it (Wilson, Barakat, Vohra, Rivto and Boon, 2008). Numerous different sources have been exposing parents to contradictory information and claims about the safety of the vaccines and the benignancy of childhood diseases (Bean, 2011). Disagreement among the medical experts is a frustrating concern for many parents, because even if they know that vaccination is supported by most of the medical community (Freed, Clark, Butchart, Singer, and Davis, 2011), they also recognise the expertise of researchers (immunologists, virologists, or microbiologists) who suggest a risk of severe long-term adverse events following immunization (Blaylock, 2004; de Brouwer, 2011; Todea-Gross, 2012; Obukhanych, 2012). Despite the fact that multiple expert committees have reviewed all original scientific research linking autism to vaccination and concluded that "The evidence favors rejection of a causal relationship between MMR vaccine and autism."(National Research Council, 2012, p.153), this concern continues to affect parents’ decisions. Scientific articles published in the last few years caution people about waning immunity after MMR and acellular pertussis vaccinations. It was also demonstrated that children born from MMR-vaccinated mothers lose protection offered by maternal antibodies at an earlier age than children of mothers who contracted the diseases (Maldonado, Lawrence, DeHovitz, Hartzell, and Albrecht, 1995; Leuridan and Van Damme, 2007; Waaijenborg et al., 2013). Decreased herd immunity leads to a delay in infection of unvaccinated individuals, but with more severe complications from the disease. In the future, the high refusal rates of MMR vaccination will probably correlate with an important increase in the number of devastating congenital rubella syndrome cases (secondary to infection with rubella in the first trimester of pregnancy). Regarding the DTaP vaccine, despite good vaccination coverage, the vaccine-derived immunity wanes over 5 to 10 years (Klein, Bartlett, Rowhani-Rahbar, Fireman, and Baxter, 2012). Therefore, pertussis occurs in older vaccinated individuals (manifested with minimal symptoms) who may then infect and cause severe disease manifestations in infants. Official data from the Washington State Department of Health showed that in the last pertussis outbreak, most of Washington’s children were vaccinated and health officials (State Secretary of Health, Mary Selecky) declared that "vaccine refusal doesn’t appear to be playing a key role in the growing pertussis burden" (Schnirring, 2012). Even if the actual pertussis vaccine is imperfect, it still plays an important part in reducing the impact of the disease, because vaccinated children have milder and less severe forms of the disease (Centers for Disease Control and Prevention - MMWR 2012, p. 520). These studies suggest that prevention of future pertussis or measles outbreaks will be best achieved by developing new, safer vaccines that could provide long-lasting immunity or by adapting the immunization schedule. The anti-vaccination movement had a negative impact on parents’ immunization behaviour. Doctors' statements such as “vaccines destroy the child's immune system” (Todea-Gross, 2012, p 33), “vaccination compromise natural
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immunity” and vaccination “increasing the risk of allergic and autoimmune manifestations” (as cited in Obukhanych, 2012); or priests' statements such as “If a mother allows her child to be vaccinated, it is like she gives him to death” (http://ortodoxia.md/despre-vaccine) are scaring people. Books and articles that were written by doctors have had a great influence on people as they make up their minds regarding vaccination decisions. The antivaccination sites or books contain many misinterpretations, and most of them present false data denying all the advantages and benefits of vaccination, such as the eradication of smallpox and the declining incidence of other infectious diseases. If lower rates of disease incidence can be explained only by high sanitation, people in Africa should still be dying from smallpox. Although the human immune system naturally adapts to challenges, some individuals cannot perfectly adjust and they risk dying from these "common" childhood diseases. It is true that natural immunity lasts longer than vaccine-induced immunity, but the risks of natural infection are greater than the secondary risks from every recommended vaccine. Communication, trust, and mutual respect are the fundamental values that must characterize the doctor-patient relationship, especially when the vaccination process is involved. In this study, we took the time to carefully listen to parents’ concerns and talk about each one of them, presenting accredited opinions regarding every specific topic. In this way, we managed to create not only a trusting relationship, but also a partnership. Within the vaccinationrelated discussions, we succeeded in convincing a few parents to change their minds and finally accept vaccination for their children (2 out of 14 complete refusals and 7 out of 12 partial refusals). When trust in the public health officials who promote vaccination fails, the compliance with immunization schedules is affected. Public health leadership efforts in spreading concern about the safety of immunization are essential for protecting public trust in immunization (Cooper, Larson, & Katz, 2008). Over the last six years in Romania, public trust in current health policies has been damaged by errors in the conduction of HPV (Human Papilloma Virus) and BCG vaccination campaigns (Pricopie, 2009; Craciun & Baban, 2012; World Health Organization, 2012). In 2009, the decision-making process regarding the influenza virus A (H1N1) crisis was lacking in transparency. In a British Medical Journal editorial, Godlee (2010) revealed conflicts of interest with WHO regarding the pandemic flu, which increased public mistrust in WHO and pharmaceutical companies. All these facts fuel the anti-vaccination movement, sometimes giving rise to unfounded and irrational fears among people, causing serious public health consequences. 5. Conclusion y Over time, public trust in the safety and efficiency of vaccination programs has been severely damaged due to the numerous contradictory statements surrounding adverse effects of immunization. Therefore, the researchers along with the government must evaluate claims against vaccines and create new health policies presenting unambiguous information regarding the safety and importance of vaccination. y Communicating the truth behind the science is complicated because medical studies use scientific language that is confusing for parents who are trying to understand the information. On the other hand, the anti-vaccination campaigns, which commonly appeal to emotions, seem to have more success. y Whether vaccination is voluntary or compulsory, each option faces complex ethical challenges because humans depend on each other in infectious diseases matter. The NIP is recommended but non-mandatory, so it should be considered that individual choices in matters of vaccination may affect the “liberty” of others. For example, decreased herd immunity does not allow those who are not eligible for vaccination to lead a normal life, because they have a higher risk of getting infections leading to severe complications. y Encouraging the refusal of vaccinations would be equivalent to returning us to past centuries and letting natural selection decide upon the survival of individuals from infectious diseases. References Bean, S. J. (2011). Emerging and continuing trends in vaccine opposition website content. Vaccine, 29(10), 1874–80. doi:10.1016/j.vaccine.2011.01.003 Blaylock, R. L. (2004). Chronic microglial activation and excitotoxicity secondary to excessive immune stimulation: Possible factors in Gulf War 9(2), 46–51. Retrieved from and autism. Journal of American Physicians and Surgeons, syndrome http://www.jpands.org/vol9no2/blaylock.pdf
Carmen Liliana Barbacariu / Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91 De Brouwer, L. (2011). Vaccinarea: Eroarea medicală a secolului, pericole și consecințe. Bucuresti: Ed. Vidia. Bumboiu, M. I., Bocșan I. S. (2005). Vaccinuri și vaccinări în practica medicală. Cluj Napoca: Editura Medicală Universitară "Iuliu Hațieganu". Centers for Disease Control and Prevention (CDC). (2011). General recommendations on immunization: Recommendations of the advisory committee on immunization practices (ACIP). Recommendations and Reports, 60(2), 1–60. Retrieved from http://www.cdc.gov/vaccines. Centers for Disease Control and Prevention (2012). Pertussis Epidemic — Washington, MMWR 2012; 61(28), 517-522. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128 a1.htm Centrul National de Supraveghere si Control al Bolilor Transmisibile (CNSCBT).(2013). Raport de activitate. Retrieved fromhttp://www.insp.gov.ro/cnscbt/index.php?option=com_docman&Itemid=11 Cooper, L. Z., Larson, H. J., Katz, S. L. (2008). Protecting public trust in immunization. Pediatrics, 122(1),149–53.doi:10.1542/peds.2008-0987 Craciun, C., Baban, A. (2012). Who will take the blame? Understanding the reasons why Romanian mothers decline HPV vaccination for their daughters. Vaccine, 30(48), 6789–93. doi:10.1016/j.vaccine.2012.09.016 Fine, P., Eames, K., & Heymann, D. L. (2011). “Herd immunity”: A rough guide. Clinical Infectious Diseases, 52(7), 911– 916.doi:10.1093/cid/cir007 Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. British Medical Journal, 309(6948), 184–188. doi:10.1136/bmj.309.6948.184. Godlee, F. (2010). Conflicts of interest and pandemic flu [Editorial]. British Medical Journal, 340. doi:http://dx.doi.org/10.1136/bmj.c2947 Retrieved March. 25, 2014 Gust, D. A., Strine, T. W., Maurice, E., Smith, P., Yusuf, H., Wilkinson, M., Schwartz, B. (2004). Under immunization among children: Effects of vaccine safety concerns on immunization status. Pediatrics, 114(1), e16–e22.doi:10.1542/peds.114.1.e16 Gust, D. A., Darling, N., Kennedy, A., Schwartz, B. (2008). Parents with doubts about vaccines: Which vaccines and reasons why. Pediatrics, 122(4), 718–725. doi:10.1542/peds.2007-0538 Klein, N. P., Bartlett, J., Rowhani-Rahbar, A., Fireman, B. & Baxter, R. (2012). Waning protection after fifth dose of acellular pertussis vaccine in children, New England Journal of Medicine,367, 1012–1019.doi:10.1056/NEJMoa1200850 Leuridan, E. &Van Damme, P. (2007). Passive transmission and persistence of naturally acquired or vaccine-induced maternal antibodies against measles in newborns. Vaccine, 25(34), 6296–304. Maldonado, Y. A., Lawrence, E. C., DeHovitz, R., Hartzell, H. &Albrecht, P. (1995). Early loss of passive measles antibody in infants of mothers with vaccine-induced immunity. Pediatrics, 96(3), 447–450. Marshall, G. S., Happe, L. E., Lunacsek, O. E., Szymanski, M. D., Woods, C. R., Zahn, M. & Russell, A. (2007). Use of combination vaccines is associated with improved coverage rates. The Pediatric Infectious Disease Journal, 26(6), 496–500. Miller, E. R., Haber, P., Hibbs, B. &Broder, K. (2011). Surveillance for adverse events following immunization using the vaccine adverse event reporting system (VAERS). In S. W. Roush, L. McIntyre, & L. Baldy (Eds.), Manual for the surveillance of vaccine-preventable diseases. Atlanta: Centers for Disease Control and Prevention (CDC). Retrieved from http://www.cdc.gov/vaccines/pubs/surv-manual/chpt21-survadverse-events.html National Research Council (2012). Adverse Effects of Vaccines: Evidence and Causality. Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/openbook.php?record_id=13164 Obukhanych, T. (2012). Vaccine illusion: How vaccination compromises our natural immunity and what we can do to regain our health. Retrieved from https://sites.google.com/site/vaccineillusion/ebook Pricopie, R. (2009). Policy dialog: The missing link in the 2008 Romanian human papilloma virus (HPV) vaccination program, Transylvanian Review of Administrative Sciences, 25(E), 92–109. Schnirring, L. (2012, July 19). CDC: Pertussis numbers suggest vaccine protection gap. Center for Infectious Disease Research and Policy (CIDRP). Minneapolis, MN: University of Minnesota. Sheriff, M. Q., Hendrix, K. S., Downs, S. M., Sturm, L. A., Zimet, G. D. & Finnell, S. M. E. (2012). The role of herd immunity in parents’ decision to vaccinate children: A systematic review. Pediatrics, 130(3), 522–530. doi:10.1542/peds.2012-0140 RSP (Societatea Română de Pediatrie) (2012). Recomandări de vaccinare în pediatrie. Ed. Medicală Almatea. Todea-Gross, C. (2012). Vaccinurile: prevenție sau boală? O nouă patologie pediatrică. Bucuresti: Ed. Christiana. Triscas, F. E. (2013). Epidemics of smallpox and the introduction of vaccines in the Bistrita region (XVIII–XIX centuries).Procedia—Social and Behavioral Sciences, 92, 947–952. Retrieved from http://dx.doi.org/10.1016/j.sbspro.2013.08.78 Waaijenborg, S., Hahné, S. J. M., Mollema, L., Smits, G. P., Berbers, G. A. M., van der Klis, F. R. M., Melker, H. E. & Wallinga J. (2013). Waning of maternal antibodies against measles, mumps, rubella, and varicella in communities with contrasting vaccination coverage, Journal of Infectious Disease, 208(1), 10–16. doi: 10.1093/infdis/jit143 Wilson, K., Barakat, M., Vohra, S., Ritvo, P. & Boon, H. (2008). Parental views on pediatric vaccination: The impact of competing advocacy Coalitions. Public Understanding of Science, 17(2), 231–243.doi: 10.1177/0963662506067662 World Health Organization (February 2014). Measles [Fact Sheet No. 286]. Retrieved March 3, 2014, from http://www.who.int/mediacentre/factsheets/fs286/en World Health Organization (2013). Causality assessment of an adverse event following Immunization (AEFI): User manual for the revised WHO classification. Geneva: Author. Retrieved fromhttp://www.who.int/vaccine_safety/publications/aevi_manual.pdf?ua=1 World Health Organization, Regional Office for Europe (2012). WHO and ECDC recommend immediate resumption of BCG vaccination programme against tuberculosis in Romania. Retrieved fromhttp://www.euro.who.int/en/countries/romania http://ortodoxia.md/despre-vaccine/2116-nu-primiti-acest-vaccin-ne-vorbeste-arhim-iustin-parvu
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LUMEN 2014
Parents' Refusal to Vaccinate Their Children: An Increasing Social Phenomenon Which Threatens Public Health Carmen Liliana Barbacariua,* a
PhD, Teaching Assistant, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, General practitioner,Individual Practice, Pacurari no. 6 Str.,Iasi, post code 700537, Romania
Abstract Over the last few years, many controversies related to immunization safety have arisen, leading to an increasing number of parents who refuse to vaccinate their children. This study investigated the reasons behind child immunization safety concerns and the parent’s sources of information. The anti-vaccination movement had a negative impact on parents’ immunization behaviour.The numerous controversies and statements surrounding immunization side effects caused an erosion of public trust in the efficiency and safety of vaccination programs. Whether vaccination is voluntary or compulsory, each option faces complex ethical challenges because humans depend on each other in infectious diseases matter. © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license © 2014 The Authors. Published by Elsevier Ltd. (http://creativecommons.org/licenses/by-nc-nd/3.0/). Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. Keywords: vaccines safety; concerns; refused; behaviour
1. Introduction Vaccines play an important role in reducing infection in a population because they are the main weapon in the fight against the common diseases that we once feared. Thanks to vaccination programs, smallpox has been eradicated and we rarely see children suffering from polio palsy, diphtheria complications, or death and brain damage from measles. For example, 1 in 200 polio infections leads to irreversible paralysis, and among those paralyzed, 5% to 10% die when their breathing muscles become immobilized; there is no cure for polio, it can only
* Corresponding author. Tel.: +40722583612. E-mail address: [email protected],
1877-0428 © 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Selection and peer-review under responsibility of the Organizing Committee of LUMEN 2014. doi:10.1016/j.sbspro.2014.08.165
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be prevented (World Health Organization, 2013). Diphtheria vaccinations have proved important because even with treatment, about 1 out of 10 diphtheria patients dies due to airway blockage, myocarditis, or severe pneumonia with respiratory failure. Unfortunately, “measles is one of the leading causes of death among young children even though a safe and cost-effective vaccine is available. In 2012, there were 122,000 measles deaths globally—about 330 deaths every day” caused by complications associated with the disease (World Health Organization, 2014). Vaccines are used to prevent the development of serious diseases in a host and are made of weakened or killed forms of bacteria or viruses, their toxins, or one of their surface proteins. These active components (the antigens) included in vaccines induce the immune response in the host’s body without passing on the real diseases. Vaccines may also contain additional components, such as preservatives (phenoxyethanol, phenol and thiomersal used to prevent contamination with fungi or bacteria), additives (to maintain the vaccine’s effectiveness by keeping the antigen stable during storage), adjuvants (various aluminium salts to enhance the immune response to a vaccine), and traces of other components (egg proteins, yeast, cell culture fluids, antibiotics, or inactivating agents left over from the process used to produce the vaccine) (Bumboiu and Bocsan, 2005, p.39). The terms immunization and vaccination are often used interchangeably, but their meanings are not exactly the same. Vaccination represents the process through which a vaccine is deliberately administered to an individual so that his immune system can prepare to fight a future infection. Immunization refers to the process by which a person becomes immune to a disease, either through vaccination or by contracting and fighting the disease naturally (Bumboiu and Bocsan, 2005, p.32). “Optimal response to a vaccine depends on multiple factors, including the type of vaccine, the age of the recipient, and immune status of the recipient. Recommendations for the age at which vaccines are administered are influenced by age-specific risks for disease, age-specific risks for complications, age-specific responses to vaccination, and potential interference with the immune response by passively transferred maternal antibodies" (Centers for Disease Control and Prevention, 2011, p. 4). In Romania, The Ministry of Health, in collaboration with The National Institute of Health, The National Centre for Infectious Disease Control and Prevention, and the Romanian Society of Pediatrics (RSP), establish a recommended schedule, free of charge, to provide routine administration of vaccines to children within the National Immunization Program (NIP).The legal framework for the NIP is established by The Ministry of Health's law No. 422/2013, and the schedule is permanently upgraded according to the World Health Organization’s (WHO) general recommendations on immunization (RSP, 2012). The number of immunizations recommended for children in the first two years of life has increased over time. In Romania, the recommended immunization schedules for 2014 included free vaccinations for 10 infectious diseases: HB (hepatitis B), BCG (Bacille de Calmette et Guérin—a vaccine against tuberculosis), DTaP/DT (diphtheria-tetanus-acellularpertussis/diphtheria-tetanus), IPV (inactivated polio vaccine), Hib (Haemophilus influenzae type b), and MMR (measles-mumps-rubella). Simplifying immunization schedules by combining multiple vaccines into a single syringe has numerous positive effects. Reducing the number of injections leads to a lower level of trauma for the infant and higher rates of compliance with complex vaccination schedules (Marshall et al., 2007). When a critical percentage (90-95%) of a population is immunized against a contagious disease, spread of the disease is reduced and most members of the community are protected. Even those who are not eligible for certain vaccines (such as young infants, pregnant women, or immune-compromised individuals such as organ transplant recipients, cancer patients, AIDS patients) or whose immune systems do not respond sufficiently to vaccination, receive some protection. This phenomenon is known as community immunity or herd immunity and it provides protection to individuals who cannot develop immunity. This indirect measure of protection raises an important issue about individual and public values (Sheriff et al., 2012). When immunization rates fall below these thresholds (90-95%), the risk of infectious outbreaks increases (measles and pertussis outbreaks have been attributed to declining herd immunity) (Fine, Eames, and Heymann, 2011). No vaccine offers complete protection, and like any medical procedure it comes with risks, even if serious side effects are mostly rare. Concerns regarding the safety of vaccines have existed in Romania since the first smallpox immunization campaigns in the eighteenth century, when only mandatory vaccination could stop the epidemic (Triscas, 2013). Over time, the public's specific concerns have changed as new vaccines have been developed and a lot of research regarding the safety of vaccines has been conducted (CDC, 2011; WHO, 2013).
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There were three goals of this study: (a) to investigate the reasons behind immunization safety concerns; (b) to identify the parents’ sources of information and their knowledge about vaccines used to prevent infectious diseases; (c) to describe the main reasons parents changed their minds about delaying or refusing a vaccine for their child. 2. Method We performed a qualitative research study within an individual family medicine practice in Iasi on a sample of parents with at least one child younger than 4 years of age (n=350). The focus group discussions were conducted individually, face to face with the parents, during the last month of pregnancy and then at their home, during the baby’s health care visit, first at several days after being discharged from the hospital and again at 1 month of age. The protocol was semi-structured with open-ended questions, allowing parents to discuss all aspects of vaccination from benefits to side effects. Furthermore, the conversation was supplemented by written material about the risks and advantages of each vaccine and information regarding the vaccine-preventable infectious diseases. The average time of each health care visit was between 30 and 60 minutes, depending on the problems and expressed concerns. Vaccine counseling and communication had been a longitudinal issue, mainly in the group of parents that refused to vaccinate their children. According to Patients’ Rights Law (No. 46/21.01.2013), the parents (the legal tutors of a child) have the responsibility to inform from accredited sources about vaccination and give their informed consent regarding the administration of vaccines to their child. Under the principle of respect for the autonomy of persons, we obtained a valid consent from individuals before vaccination. The data were systematized and a qualitative thematic analysis was performed to explore factors that influenced parents' decisions to refuse vaccination. 3. Results 3.1 Characteristics of study sample Among the 350 children under 4 years old (born between 2010 and 2013), we identified 26 (7.4%) children (from 24 families) whose parents refused all (n=14 children unvaccinated) or some (n=12 under vaccinated) of the vaccinations within the NIP. Demographic characteristics of the 24 families who refused vaccination are shown in Table 1. Table 1. Demographic characteristics of 24 families refusing child vaccination Characteristics Parent age
Parent education Birth year
Number of children in family
24-30 30 – 35 35 – 40 High school University 2010 2011 2012 2013 1 2 3 4
No
%
14 24 6 8 40 2 5 13 6 14 9 1 2
29 58 13 17 83 8 19 50 23 53 35 4 8
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Most families were young (87% of parents were between 24 and 35 years old) and had only one child (15 out of 26 children, 58%). Nine families had two children (in two cases parents refused vaccination for both children). Two families had four children and one family had three children (all of them were vaccinated except the youngest one). The study group included socially privileged people with a high level of education. Most of the parents (83%, or 20 out of 24 families) refusing vaccination had academic studies, while parents in four families had graduated only high school. Comparing children based on their birth year (2010 to 2013), we found a progressive increase of vaccine refusal over time, with a peak in 2012 (13 refusals out of 84, 15%) and also a spike of complete refusals among the children born in the second half of 2013 (6 complete refusals out of 85, 7%) (see Figure 1).
DTaP-Hib-IPV booster +MMR refusal MMR refusal
100% 95%
90% 85%
complete refusal of vaccination
80%
fully vaccinated 2010
2011
2012
We also found an increased refusal of DTaP-Hib-IPV booster and MMR among parents with children born in 2011 and 2012, because they changed their mind, to ultimately refuse vaccination. Of those who had refused at least one vaccine, MMR was the most commonly refused (100%), followed by the DTaPIPV-Hib booster (6 out of 12, 50%).
2013
Fig. 1.Trend of vaccination refusal over the four year study in the target group
Assessment of the reasons for vaccination refusal implied detailed analyses for each specific concern in the parental decision-making process. 3.2 Specific vaccine-related concerns expressed by parents y All parents were worried that the increasing number of recommended vaccines for babies at such a young age would overload the immature immune system. In 3 out of the 14 families who completely refused vaccination, this was the motivation for delaying their children’s vaccinations beyond the age of 24 months when the immune system should be more robust. y The diseases have disappeared, so why still vaccinate? This question was mentioned by most of the parents who completely refused vaccination. Nowadays, parents with young children do not have personal experience with poliomyelitis, diphtheria, or other vaccine-preventable diseases. As a result, they perceive low potential health risks from getting these infectious diseases. y Vaccines do not protect against the infectious diseases, they are unnecessary and do not work. Parents who refused all vaccines for their children were convinced that the incidence of infectious diseases had declined decades before the introduction of vaccination and it was primarily due to better personal hygiene, improved sanitation, good nutrition, and generally improved quality of life. They were convinced that despite the mass immunization programs, fully vaccinated populations have experienced epidemics. Some parents described close friends' negative experiences with their vaccinated children who got the disease. y Perceived advantages of having a disease were claimed by all parents regarding the MMR vaccine. They considered that measles, mumps, and rubella are specific childhood diseases without serious complications and that children will gain long lasting immunity after naturally fighting the diseases, compared to specific vaccination. Despite the fact that most of the parents were frightened about their child getting poliomyelitis, three parents argued that infection with polio virus is asymptomatic in 90% of cases; therefore, they did not consider vaccination as being mandatory. All of the parents who completely refused vaccination thought that their children would be healthier
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without it. y Most of the concerns were related to vaccine safety, and this is an important issue to discuss. Every parent involved in the vaccination decision-making process was frightened due to the controversial information coming from doctors who reported thousands of serious adverse vaccine reactions each year, including hundreds of deaths and permanent disabilities. Parents have read about the compensations for vaccine injuries in the United States. Hundreds of persons who filed a claim were paid money by the National Vaccine Injury Compensation Program (VICP), secondary to the decision of the United States Court of Federal Claims (Court). There are serious fears in relation to toxic components in vaccines. Such fears include the beliefs that their additives/adjuvants (thiomersal, aluminium, and phenoxyethanol) induce brain injury, autism, and other developmental disorders and that cell culture fluids with foreign DNA (Deoxyribonucleic acid) are considered to be the cause of the “cancer epidemic” or even AIDS. Moreover, autoimmune diseases such as asthma and other allergic diseases, multiple sclerosis, and sudden death in children were thought to have been caused by vaccination. y Some parents refused to have their children vaccinated, not because they feared autism, but because they mistrusted drug companies, government ministers, public health officials, and health policies. This attitude was observed mainly in association with big scandals related to adverse reactions secondary to BCG administrated in 2012. The majority of vaccination refusals in this study group were in 2012 (13 out of 84 children, 15%). y There were some families who reported negative experiences with vaccination. In this group, there were two families, having two children each, who refused to vaccinate their younger child because their elder one experienced multiple episodes of wheezing associated with viral infections and atopic dermatitis, problems for which parents blamed the vaccines. Despite this precaution, the unvaccinated children expressed the same symptoms, which proved a hereditary predisposition toward developing certain hypersensitivity reactions rather than adverse reactions caused by vaccines. y Finally, 7 out of 24 families admitted that they used alternative therapies such as homeopathy or that they believed Hamer's Germanic New Medicine, a system of pseudo-medicine that purports to be able to cure cancer, (Hamer lost his practice license in 1986 for malpractice) and other alternative medicine (naturopathy, energy medicine, and acupuncture), choosing to refuse conventional vaccines for their babies. 3.3 Parents' sources of information involved in the vaccination decision-making process The decision parents face regarding child immunization is a complex one, founded on numerous sources of information available. In this focus group, 20 out of 24 parents (83%) refusing vaccination had academic studies. Despite the high level of education, their decisions were not always based on scientific evidence. The analysis revealed that the sources of information approach very different perspectives. The parents accessed information from traditional sources, such as public health officials and physicians opinions (often with conflicting information), to nontraditional sources, such as online parents forums; press articles; television shows such as Romania, I Love You - Vaccines: Myth and Truth (ProTv, aired on 9 June 2013); anti-vaccination blogs and websites such as http://bucovinaprofunda.wordpress.com/category/antivaccin; and anti-vaccination books (de Brouwer, 2011; Todea-Gross, 2012). 4. Discussion Over the last few years, many controversies related to immunization safety have arisen, leading to an increasing number of parents who refuse to vaccinate their children. Their refusal is influenced by underestimating the severity of possible complications following preventable diseases while overestimating the vaccines’ side effects (Gust et al., 2004; Gust, Darling, Kennedy, & Schwartz, 2008). Our results reflected a decrease in vaccination coverage, a tendency also observed in the statistics reports of the Romanian National Centre for Infectious Disease Control and Prevention (CNSCBT, 2013). Vaccine coverage reported in clusters of babies born between 2008 and 2011 revealed a decrease from over 95% in 2008 to around 80% in 2011 (Table 2). The vaccination refusal percent had risen from 22.4% for those born in 2009 to 33.2% for those born in 2011, with higher rates of refusal in the urban area (CNSCBT, 2010-2013).
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Carmen Liliana Barbacariu / Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91 Table 2. Romania’s vaccination coverage reports from CNSCBT on 2010 – 2013 clusters of 2-year-old children Vaccine type
Vaccine coverage at 24 months (%) Born July 2008 Born July 2009
Born July 2010
Born July 2011
BCG 1
98.7
92.6
85.4
85.8
HB 3 doses DTaP booster IPV booster Hib booster MMR 1
97.7 95 95 96.5
90.5 87.4 87.4 88.6
83.5 81.1 81.0 81.0 82.0
83.6 79.8 79.7 79.7 81.7
Vaccination remains an emotional issue for many parents and general practitioners due to ethical crises that often arise. The “four principles” approach postulated by Tom Beauchamp and James Childress in their 2009 textbook, Principles of Biomedical Ethics must be taken into account while trying to find the best solution for ethical dilemmas (Gillon, 1994). Under the principle of autonomy, parents have the right to refuse vaccination for their children, a decision which is best made after being properly informed by accredited sources. Since vaccination is a preventative measure and not a treatment for a particular disease, the "first, do no harm" principle must guide all actions for the child’s best interest, also respecting the principle of beneficence. Vaccination refusal was found to rely on multiple factors including cultural, emotional, religious, and social issues. As in many other countries, in Romania there is a constant debate regarding paediatric vaccination policies between two distinct coalitions: those in favour of vaccination within NIP and those expressing concerns about it (Wilson, Barakat, Vohra, Rivto and Boon, 2008). Numerous different sources have been exposing parents to contradictory information and claims about the safety of the vaccines and the benignancy of childhood diseases (Bean, 2011). Disagreement among the medical experts is a frustrating concern for many parents, because even if they know that vaccination is supported by most of the medical community (Freed, Clark, Butchart, Singer, and Davis, 2011), they also recognise the expertise of researchers (immunologists, virologists, or microbiologists) who suggest a risk of severe long-term adverse events following immunization (Blaylock, 2004; de Brouwer, 2011; Todea-Gross, 2012; Obukhanych, 2012). Despite the fact that multiple expert committees have reviewed all original scientific research linking autism to vaccination and concluded that "The evidence favors rejection of a causal relationship between MMR vaccine and autism."(National Research Council, 2012, p.153), this concern continues to affect parents’ decisions. Scientific articles published in the last few years caution people about waning immunity after MMR and acellular pertussis vaccinations. It was also demonstrated that children born from MMR-vaccinated mothers lose protection offered by maternal antibodies at an earlier age than children of mothers who contracted the diseases (Maldonado, Lawrence, DeHovitz, Hartzell, and Albrecht, 1995; Leuridan and Van Damme, 2007; Waaijenborg et al., 2013). Decreased herd immunity leads to a delay in infection of unvaccinated individuals, but with more severe complications from the disease. In the future, the high refusal rates of MMR vaccination will probably correlate with an important increase in the number of devastating congenital rubella syndrome cases (secondary to infection with rubella in the first trimester of pregnancy). Regarding the DTaP vaccine, despite good vaccination coverage, the vaccine-derived immunity wanes over 5 to 10 years (Klein, Bartlett, Rowhani-Rahbar, Fireman, and Baxter, 2012). Therefore, pertussis occurs in older vaccinated individuals (manifested with minimal symptoms) who may then infect and cause severe disease manifestations in infants. Official data from the Washington State Department of Health showed that in the last pertussis outbreak, most of Washington’s children were vaccinated and health officials (State Secretary of Health, Mary Selecky) declared that "vaccine refusal doesn’t appear to be playing a key role in the growing pertussis burden" (Schnirring, 2012). Even if the actual pertussis vaccine is imperfect, it still plays an important part in reducing the impact of the disease, because vaccinated children have milder and less severe forms of the disease (Centers for Disease Control and Prevention - MMWR 2012, p. 520). These studies suggest that prevention of future pertussis or measles outbreaks will be best achieved by developing new, safer vaccines that could provide long-lasting immunity or by adapting the immunization schedule. The anti-vaccination movement had a negative impact on parents’ immunization behaviour. Doctors' statements such as “vaccines destroy the child's immune system” (Todea-Gross, 2012, p 33), “vaccination compromise natural
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immunity” and vaccination “increasing the risk of allergic and autoimmune manifestations” (as cited in Obukhanych, 2012); or priests' statements such as “If a mother allows her child to be vaccinated, it is like she gives him to death” (http://ortodoxia.md/despre-vaccine) are scaring people. Books and articles that were written by doctors have had a great influence on people as they make up their minds regarding vaccination decisions. The antivaccination sites or books contain many misinterpretations, and most of them present false data denying all the advantages and benefits of vaccination, such as the eradication of smallpox and the declining incidence of other infectious diseases. If lower rates of disease incidence can be explained only by high sanitation, people in Africa should still be dying from smallpox. Although the human immune system naturally adapts to challenges, some individuals cannot perfectly adjust and they risk dying from these "common" childhood diseases. It is true that natural immunity lasts longer than vaccine-induced immunity, but the risks of natural infection are greater than the secondary risks from every recommended vaccine. Communication, trust, and mutual respect are the fundamental values that must characterize the doctor-patient relationship, especially when the vaccination process is involved. In this study, we took the time to carefully listen to parents’ concerns and talk about each one of them, presenting accredited opinions regarding every specific topic. In this way, we managed to create not only a trusting relationship, but also a partnership. Within the vaccinationrelated discussions, we succeeded in convincing a few parents to change their minds and finally accept vaccination for their children (2 out of 14 complete refusals and 7 out of 12 partial refusals). When trust in the public health officials who promote vaccination fails, the compliance with immunization schedules is affected. Public health leadership efforts in spreading concern about the safety of immunization are essential for protecting public trust in immunization (Cooper, Larson, & Katz, 2008). Over the last six years in Romania, public trust in current health policies has been damaged by errors in the conduction of HPV (Human Papilloma Virus) and BCG vaccination campaigns (Pricopie, 2009; Craciun & Baban, 2012; World Health Organization, 2012). In 2009, the decision-making process regarding the influenza virus A (H1N1) crisis was lacking in transparency. In a British Medical Journal editorial, Godlee (2010) revealed conflicts of interest with WHO regarding the pandemic flu, which increased public mistrust in WHO and pharmaceutical companies. All these facts fuel the anti-vaccination movement, sometimes giving rise to unfounded and irrational fears among people, causing serious public health consequences. 5. Conclusion y Over time, public trust in the safety and efficiency of vaccination programs has been severely damaged due to the numerous contradictory statements surrounding adverse effects of immunization. Therefore, the researchers along with the government must evaluate claims against vaccines and create new health policies presenting unambiguous information regarding the safety and importance of vaccination. y Communicating the truth behind the science is complicated because medical studies use scientific language that is confusing for parents who are trying to understand the information. On the other hand, the anti-vaccination campaigns, which commonly appeal to emotions, seem to have more success. y Whether vaccination is voluntary or compulsory, each option faces complex ethical challenges because humans depend on each other in infectious diseases matter. The NIP is recommended but non-mandatory, so it should be considered that individual choices in matters of vaccination may affect the “liberty” of others. For example, decreased herd immunity does not allow those who are not eligible for vaccination to lead a normal life, because they have a higher risk of getting infections leading to severe complications. y Encouraging the refusal of vaccinations would be equivalent to returning us to past centuries and letting natural selection decide upon the survival of individuals from infectious diseases. References Bean, S. J. (2011). Emerging and continuing trends in vaccine opposition website content. Vaccine, 29(10), 1874–80. doi:10.1016/j.vaccine.2011.01.003 Blaylock, R. L. (2004). Chronic microglial activation and excitotoxicity secondary to excessive immune stimulation: Possible factors in Gulf War 9(2), 46–51. Retrieved from and autism. Journal of American Physicians and Surgeons, syndrome http://www.jpands.org/vol9no2/blaylock.pdf
Carmen Liliana Barbacariu / Procedia - Social and Behavioral Sciences 149 (2014) 84 – 91 De Brouwer, L. (2011). Vaccinarea: Eroarea medicală a secolului, pericole și consecințe. Bucuresti: Ed. Vidia. Bumboiu, M. I., Bocșan I. S. (2005). Vaccinuri și vaccinări în practica medicală. Cluj Napoca: Editura Medicală Universitară "Iuliu Hațieganu". Centers for Disease Control and Prevention (CDC). (2011). General recommendations on immunization: Recommendations of the advisory committee on immunization practices (ACIP). Recommendations and Reports, 60(2), 1–60. Retrieved from http://www.cdc.gov/vaccines. Centers for Disease Control and Prevention (2012). Pertussis Epidemic — Washington, MMWR 2012; 61(28), 517-522. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6128 a1.htm Centrul National de Supraveghere si Control al Bolilor Transmisibile (CNSCBT).(2013). Raport de activitate. Retrieved fromhttp://www.insp.gov.ro/cnscbt/index.php?option=com_docman&Itemid=11 Cooper, L. Z., Larson, H. J., Katz, S. L. (2008). Protecting public trust in immunization. Pediatrics, 122(1),149–53.doi:10.1542/peds.2008-0987 Craciun, C., Baban, A. (2012). Who will take the blame? Understanding the reasons why Romanian mothers decline HPV vaccination for their daughters. Vaccine, 30(48), 6789–93. doi:10.1016/j.vaccine.2012.09.016 Fine, P., Eames, K., & Heymann, D. L. (2011). “Herd immunity”: A rough guide. Clinical Infectious Diseases, 52(7), 911– 916.doi:10.1093/cid/cir007 Gillon, R. (1994). Medical ethics: Four principles plus attention to scope. British Medical Journal, 309(6948), 184–188. doi:10.1136/bmj.309.6948.184. Godlee, F. (2010). Conflicts of interest and pandemic flu [Editorial]. British Medical Journal, 340. doi:http://dx.doi.org/10.1136/bmj.c2947 Retrieved March. 25, 2014 Gust, D. A., Strine, T. W., Maurice, E., Smith, P., Yusuf, H., Wilkinson, M., Schwartz, B. (2004). Under immunization among children: Effects of vaccine safety concerns on immunization status. Pediatrics, 114(1), e16–e22.doi:10.1542/peds.114.1.e16 Gust, D. A., Darling, N., Kennedy, A., Schwartz, B. (2008). Parents with doubts about vaccines: Which vaccines and reasons why. Pediatrics, 122(4), 718–725. doi:10.1542/peds.2007-0538 Klein, N. P., Bartlett, J., Rowhani-Rahbar, A., Fireman, B. & Baxter, R. (2012). Waning protection after fifth dose of acellular pertussis vaccine in children, New England Journal of Medicine,367, 1012–1019.doi:10.1056/NEJMoa1200850 Leuridan, E. &Van Damme, P. (2007). Passive transmission and persistence of naturally acquired or vaccine-induced maternal antibodies against measles in newborns. Vaccine, 25(34), 6296–304. Maldonado, Y. A., Lawrence, E. C., DeHovitz, R., Hartzell, H. &Albrecht, P. (1995). Early loss of passive measles antibody in infants of mothers with vaccine-induced immunity. Pediatrics, 96(3), 447–450. Marshall, G. S., Happe, L. E., Lunacsek, O. E., Szymanski, M. D., Woods, C. R., Zahn, M. & Russell, A. (2007). Use of combination vaccines is associated with improved coverage rates. The Pediatric Infectious Disease Journal, 26(6), 496–500. Miller, E. R., Haber, P., Hibbs, B. &Broder, K. (2011). Surveillance for adverse events following immunization using the vaccine adverse event reporting system (VAERS). In S. W. Roush, L. McIntyre, & L. Baldy (Eds.), Manual for the surveillance of vaccine-preventable diseases. Atlanta: Centers for Disease Control and Prevention (CDC). Retrieved from http://www.cdc.gov/vaccines/pubs/surv-manual/chpt21-survadverse-events.html National Research Council (2012). Adverse Effects of Vaccines: Evidence and Causality. Washington, DC: The National Academies Press. Retrieved from http://books.nap.edu/openbook.php?record_id=13164 Obukhanych, T. (2012). Vaccine illusion: How vaccination compromises our natural immunity and what we can do to regain our health. Retrieved from https://sites.google.com/site/vaccineillusion/ebook Pricopie, R. (2009). Policy dialog: The missing link in the 2008 Romanian human papilloma virus (HPV) vaccination program, Transylvanian Review of Administrative Sciences, 25(E), 92–109. Schnirring, L. (2012, July 19). CDC: Pertussis numbers suggest vaccine protection gap. Center for Infectious Disease Research and Policy (CIDRP). Minneapolis, MN: University of Minnesota. Sheriff, M. Q., Hendrix, K. S., Downs, S. M., Sturm, L. A., Zimet, G. D. & Finnell, S. M. E. (2012). The role of herd immunity in parents’ decision to vaccinate children: A systematic review. Pediatrics, 130(3), 522–530. doi:10.1542/peds.2012-0140 RSP (Societatea Română de Pediatrie) (2012). Recomandări de vaccinare în pediatrie. Ed. Medicală Almatea. Todea-Gross, C. (2012). Vaccinurile: prevenție sau boală? O nouă patologie pediatrică. Bucuresti: Ed. Christiana. Triscas, F. E. (2013). Epidemics of smallpox and the introduction of vaccines in the Bistrita region (XVIII–XIX centuries).Procedia—Social and Behavioral Sciences, 92, 947–952. Retrieved from http://dx.doi.org/10.1016/j.sbspro.2013.08.78 Waaijenborg, S., Hahné, S. J. M., Mollema, L., Smits, G. P., Berbers, G. A. M., van der Klis, F. R. M., Melker, H. E. & Wallinga J. (2013). Waning of maternal antibodies against measles, mumps, rubella, and varicella in communities with contrasting vaccination coverage, Journal of Infectious Disease, 208(1), 10–16. doi: 10.1093/infdis/jit143 Wilson, K., Barakat, M., Vohra, S., Ritvo, P. & Boon, H. (2008). Parental views on pediatric vaccination: The impact of competing advocacy Coalitions. Public Understanding of Science, 17(2), 231–243.doi: 10.1177/0963662506067662 World Health Organization (February 2014). Measles [Fact Sheet No. 286]. Retrieved March 3, 2014, from http://www.who.int/mediacentre/factsheets/fs286/en World Health Organization (2013). Causality assessment of an adverse event following Immunization (AEFI): User manual for the revised WHO classification. Geneva: Author. Retrieved fromhttp://www.who.int/vaccine_safety/publications/aevi_manual.pdf?ua=1 World Health Organization, Regional Office for Europe (2012). WHO and ECDC recommend immediate resumption of BCG vaccination programme against tuberculosis in Romania. Retrieved fromhttp://www.euro.who.int/en/countries/romania http://ortodoxia.md/despre-vaccine/2116-nu-primiti-acest-vaccin-ne-vorbeste-arhim-iustin-parvu
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