By Debra A. Cooper, RN, MSN, MBA/HCM, CIC®, CPHRM

This year has had its share of communicable disease outbreaks. An outbreak, as defined by the World Health Organization (WHO), is “the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season.”1 The Centers for Disease Control and Prevention (CDC) noted that the U.S. had more than 1,000 cases of measles in the first six months of 2019, which is more than the number of reported cases in all of 2018.2,3 This measles outbreak, however, is not the only problem – mumps, pertussis, and varicella have been reported in record numbers as well.4,5,6

Whether it be measles, mumps, pertussis, or varicella, each has at least two things in common: They are considered vaccine preventable, and they are considered childhood illnesses. While the focus of this article is on the pediatric population, it should be noted that these illnesses can occur in adults and when they do, they are often more severe than they are in children.7 The risk of serious complications, including death, from a vaccine-preventable illness is real. Testimonies of families who share their personal experiences are heartbreaking.

It seems simple. If vaccines can prevent serious illness, why don’t people get vaccinated? While the mythology surrounding vaccines may play a role in lower immunization rates, there are other reasons for vaccination refusal and hesitancy. A study published in The Journal of Pediatric Pharmacology and Therapeutics notes that while the reasons parents give vary, they generally fall into four main categories: religious objections, personal philosophical beliefs, safety concerns, and a need for additional information from clinicians.8

Some clinicians, frustrated by parents who refuse to vaccinate their children, have implemented (or would like to implement) a policy for discharging patients who refuse vaccination from their practice. This can be a slippery slope, given that various state statutes allow vaccination exemptions under
certain circumstances.

Exploring and understanding parental reasoning is important. For example, a parent’s apparent refusal to vaccinate their child may actually be vaccine hesitancy due to lack of information. The American Academy of Pediatrics (AAP) states, “Providing parents (or guardians) with an opportunity to ask questions about their concerns regarding recommended childhood immunizations, attempting to understand parents’ reasons for refusing one or more vaccines, and maintaining a supportive relationship with the family are all part of a good risk management strategy.”9 Understanding the difference between vaccine refusal and vaccine hesitancy is important. Knowing what to do when confronted by either of these situations is vital.

Vaccine Refusal

Vaccine refusal is defined as: “Unwillingness to allow oneself or a family member to be immunized
against a preventable contagious disease, such as measles, mumps, rubella, or chickenpox. It occurs most often in people who fear adverse effects from vaccination, in people who have religious or philosophical objections to vaccination, and in people who have had allergies to a component of a vaccine.”10

Absolute refusal does not abdicate a practitioner’s responsibility to provide information about vaccines. The individual refusing vaccination must still receive vaccine-specific information, which is available in a Vaccine Information Statement (VIS). The AAP offers several recommendations should a parent (or guardian) refuse to vaccinate their child:

  • Discuss risks associated with under- or nonimmunized children.
  • Give parents the vaccine-specific VIS during vaccination visits and answer their questions.
  • Have the parent sign a Refusal to Vaccinate form and maintain that form in the child’s medical record. The AAP provides a Refusal to Vaccinate form.
  • Repeat discussions regarding the benefits and risks at each subsequent visit.
  • Flag the medical records of unvaccinated or partially vaccinated children. This can serve as a reminder to resume vaccination discussions as well as alert clinicians when evaluating a child who presents to the office with a fever of unknown cause.
  • Document all discussions and any information provided, like the VIS, in the medical record.10

Vaccine Hesitancy

“‘Vaccine hesitancy’ is a relatively new term used in research over the past few years to describe anyone who is doubtful about vaccinations or who chooses to delay or refuse immunizations even when they are readily available.”8 Often-cited reasons for vaccine hesitancy include a fear that a vaccine may be harmful, a misunderstanding or lack of understanding regarding the vaccine, or a belief that their child doesn’t need the vaccination because the odds of contracting the vaccine-preventable disease are minimal.9

Vaccination Exemption Resources

Vaccination exemptions, which include religious, medical, and philosophical reasons, vary from state to state. In addition to publishing recommended vaccination schedules, the CDC provides a useful tool that clinicians may use to access vaccination laws/exemptions in their state, along with qualifications for the noted exemptions. The CDC’s Polar Graph on State School Vaccination Exemptions Law provides an “at a glance” pictorial representation of all exemptions each state allows.

The National Vaccine Information Center (NVIC) is another resource clinicians can use when seeking answers regarding exemptions. In addition to a wealth of other vaccine-related information, the NVIC website provides answers to frequently asked questions about vaccine exemptions and a map/pictorial of exemptions by state, exemption requirements, and waivers.

The advent of vaccines to prevent childhood illnesses is undeniably regarded as a success of modern medicine. Despite recommended schedules and vaccination laws, however, outbreaks of one or more vaccine-preventable childhood illnesses occur annually. Although there are times when legitimate religious, medical, or philosophical exemptions thwart vaccination attempts, there are also times when simply providing additional information and answering questions can result in another vaccinated child.


Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.