Thesis Paper

Review of the Literature

A literature review search was conducted in order to retrieve articles relevant to the topic

of vaccination and the various beliefs, benefits, and consequences of such. The articles retrieved

focused on various areas including both individual and family beliefs of vaccination

encompassing the proponents and opponents of vaccination. Numerous risk factors and benefits

associated with vaccination, contributing factors to hesitancy, and conflicting attitudes were

examined in an attempt to combat the controversial issue at various levels. Another important

component to cover is the controversy or political debate of mandatory governmental regulations

were reviewed. In addition to hesitancy, it was also important to review the risks that adhere to

hesitancy risks.

Complications and Challenges

There are many symptoms or side effects that can result from vaccination. The National

Vaccine Information Center (NVIC) (2016b) identifies the most common side effects, which

comprise of swelling or redness, inconsolable crying, joint pain or muscle weakness, excessive

bruising, body rash, high fever, fatigue, diarrhea, and twitching of the body. Similar to any

medical intervention, risks associated with vaccines can result in either the product not working,

or the product causing harm. According to the NVIC (2016b), the following are considered to be

the most common complications connected to vaccination: brain inflammation, anaphylaxis,

Chronic Nervous System Dysfunction (CNSD), febrile seizures, acute and chronic arthritis,

brachial neuritis, thrombocytopenia; smallpox, polio, measles and varicella zoster vaccine strain

infection, deltoid bursitis, syncope, shock, inconsolable crying, and death. Due to the lack of

methodological sound studies, the Institute of Medicine IOM is unable to confirm or deny the

connection between the present childhood vaccination schedule and chronic brain and immune

disorders such as asthma, autism, allergies, seizures, Tourette’s syndrome, and other learning

disorders (NVIC, 2016b).

A recent challenge occurring in 2015 was the measles outbreak that occurred in the U.S.

with over 120 people in 17 various states (Poland. & Poland, 2015). The primary cause of this

outbreak was identified as the increased rates of vaccination hesitation or refusal (Poland &

Poland, 2015). According to Pullen (2016), more than half (56.8%) of recent measles cases in

the U.S. can be attributed to vaccine refusal. In addition, 24% - 45% of recent pertussis outbreaks

occurred in unvaccinated individuals or vaccinated individuals living in a location with a high

prevalence of vaccine exemptions (Pullen, 2016).

In accordance with the NVIC (2016b), a campaign was created in 2015 to advocate for

vaccine risk awareness and the right to exercise vaccination as a voluntary option for caregivers

to children. This campaign is known as No Forced Vaccination and is another challenge for

promoting vaccination. It was endorsed by NVIC in 1982 to prevent vaccine related injuries and

death through educating the general public (NVIC, 2016b).

Another reticence challenge presented by vaccines would be individual susceptibility to

vaccine reactions. According to NVIC (2016b), the IOM published a report, Adverse Effects of

Vaccines: Evidence and Causality, in 2012 stating there are high risk factors that can increase

individual susceptibility to vaccine reactions. This report implies that most people who

experience an adverse reaction to vaccination have a pre-existing susceptibility that may include

and are not limited to: genetic variants, environmental factors, intervening illness, behaviors, and

other predispositions (NVIC, 2016b). It is critical for health-care providers, caregivers, and

patients alike to be educated on the various challenges, complications, and risks association with

vaccines.

Attitudes and Beliefs

According to Fredrickson et al. (2004), approximately, three out of four children are

vaccinated in the U.S. Vaccination concerns encompass a large spectrum of hesitations that

range from outright refusal to vaccinate to a delay in the standard vaccination schedule.

According to a qualitative study on risk perception of diseases and decisions surrounding

vaccines, proponents of vaccines fear unfamiliar disease, while opponents fear unknown side

effects (Bond & Nolan, 2011). Refusal varies greatly among individuals or caregivers, but

according to McKee and Bohannon (2016), there are four predominant categories for parents

which consist of safety concerns, personal or philosophical reasons, the need for more

information from healthcare providers, and religious beliefs being the largest contributor.

Safety concerns are typically media driven or word of mouth, making it particularly

challenging for individuals or caregivers to make a well-informed decision on vaccination and to

sort through the accurate and inaccurate data. Public health experts identify the prevalence of

hesitations, fears, and misinformation surrounding vaccines from the media as an indicator of the

public confidence levels declining (Kennedy, Nowak, Basket, & Landry, 2011). Reports show

vaccines can cause brain damage, autism, or behavioral problems cause individuals or caregivers

to be more hesitant and hold more concerns of vaccination (McKee & Bohannon, 2016). Some

people fear that administering various strains of vaccines into an individual can lead to

overloading an immune system and increase the safety risk (McKee & Bohannon, 2016). An

additional safety concern is that there are more side effects associated with vaccines than what is

disclosed from their healthcare provider (Harmsen et al., 2013).

Even though only a handful of states offer exemptions for personal or philosophical

beliefs, it still remains a common reason that individuals or caregivers delay or refuse

vaccination. Some people belief that natural immunity is more superior than vaccine related

immunity or to have their children contract particular preventable diseases claiming it makes

their immune system stronger in the long run (Fredrickson et al., 2004). Others like McKee &

Bohannon (2016) believe the infectious diseases in which are currently prevented through

vaccination are not very prevalent and individuals are at minimal risk. An additional personal

belief discovered, is the notion of maintaining a healthy diet to decrease risk of contracting a

preventable disease. Another philosophical view is that vaccines are unnecessary chemicals to

add into the body (McKee & Bohannon, 2016).

The third component identified by McKee and Bohannon (2016) is that people just want

more information regarding vaccines, the side effects and benefits, and the risks and benefits

associated. It is crucial for healthcare providers and pharmacists to provide factual, unbiased,

reliable information related to vaccines (Wilson et al., 2015). Others want to have open

conversations with their providers without the fear of being attacked or judged for asking

questions (Fredrickson et al., 2004). A study conducted by Kennedy et al. (2011), revealed that

nearly 82% of parents value their healthcare provider’s opinion most. It is important to note that

when individuals or caregivers do not get the information they are seeking from their provider,

they then resort to other sources of information that could tend to be unreliable or misleading

(McKee & Bohannon, 2016).

Religious beliefs stem from the core beliefs of an individual, and as a result tend to be the

most challenging in persuasion for vaccination and are most often linked to downright refusing

all vaccines (Kennedy et al., 2011). Conservative religious groups are one of the strongest

opponents of mandatory vaccines, particularly depending of the type of vaccine. For example,

Lawrence and Gostin (2011) suggest that certain religious believers perceive mandating the HPV

vaccine would only condone adolescent sexual behaviors. Wombell et al. (2015), evaluated

various religions and concluded that it is attributed to the materials that make up the vaccines

that go against their religion. For example, there is an animal derived gelatin or human fetus

tissue used in some vaccines (Wombell et al., 2015).

Proponents of vaccination believe that vaccines can save lives and the ingredients found

in vaccines are safe. Common substances found in vaccines such as aluminum, formaldehyde,

and thimerosal can be harmful in substantial quantities, but not in the limited volume found in

vaccines. Proponents argue that children are exposed to higher volumes of aluminum in infant

formula or breast milk than from a vaccine (ProCon, 2016). Proponents would also point out

that many medical organizations are fully supportive of vaccines such as the CDC, HHS, and

WHO (American Academy of Pediatrics, 2016). Another argument in response to the

controversial idea of “adverse reactions,” would be that these occurrences are enormously rare.

According to the report, Vaccines are safe, hazards few and far between, published by National

Public Radio (NPR), the most common side effect of vaccines is an allergic reaction and only

occurs in one per million vaccinations administered to children (Schute, 2011). An additional

strength of vaccination is the idea that it provides herd immunity, or community immunity

(USHHS, 2016).

A large case made in favor of vaccination is the fact that vaccines have eradicated

infectious disease such as smallpox (CDC Emergency Risk Communication Branch, 2016). In

addition, supporters of vaccination would argue that vaccines save children, parents, and other

patient’s time and money in comparison to the time and cost of obtaining an infectious disease

(CDC, 2011a). Another economic benefit is that vaccinations provide financial benefits for

society. For example, the CDC (2011b) estimates all children who received vaccination between

1994 and 2014 have totaled a net savings of $1.38 trillion throughout society. Moreover,

proponents believe that vaccines protect future generations: mothers who are vaccinated

ultimately protect their unborn children from viruses, like vaccinated communities help eliminate

infectious diseases for future populations (CDC, 2011a).

On the contrary, vaccination opponents would argue that vaccines can cause serious and

even fatal side effects and should not be made mandatory by the government (CDC, 2015b).

Some individuals and caregivers are known to be more concerned about the safety of the vaccine

instead of the diseases they can prevent (Smith, 2015). Anti-supporters would make the

argument that compulsory vaccination infringes upon an individual’s constitutional right of

religious freedoms (ProCon, 2016). Some opponents believe that because particular

combinations of vaccines (DTap, IPV, Hib, Hep A, Hep B, MMR, and/or chicken pox) contain

ingredients that are considered immoral and objectionable (Vatican, 2005). These particular

vaccines were derived from two aborted fetuses from the 1960’s while others were derived from

human albumin, a blood plasma protein, both considered to be problematic and unnatural

(Vatican, 2005). Some opponents also believe that the FDA, CDC, and pharmaceutical

companies should not be trusted to create and regulate vaccines due to ethics and profitability

(Autism One, 2014).

The NVIC (2016a) claims that vaccination could be linked to asthma, learning

disabilities, autism, chronic inflammation, and diabetes, just to name a few. Opponents would

make the case that vaccines do contain harmful ingredients. For instance, aluminum can cause

neurological harm in high doses, formaldehyde can cause side effects like an alteration in

cognitive function, coma, cardiac impairment, convulsions, and even death, and thimerosal can

be linked to autism (NVIC, 2016a). Vaccination challengers would also point out that natural

immunity, or the body’s ability to fight off infection naturally, is more effective and natural than

vaccination which is artificial. Lastly, many opponents consider most diseases that have been

targeted by vaccines (chicken pox, measles, rubella, and rotavirus) are considered to be

reasonably risk-free, therefore deeming vaccines to be unnecessary (ProCon, 2016).

Efficacy

Vaccine preventable diseases consist of measles, mumps, polio, rubella, diphtheria,

pertussis, and Hib (Bartlett, 2014). Polio and Diphtheria have both had a 100% reduction rate

before these vaccines were offered to recent surveillance data portrayed by the CDC (2014).

Measles, mumps, rubella, and Hib are over a 96% reduction rate since the birth of these vaccines,

while pertussis’ reduction rate is about 68% since its vaccine was created (Bartlett, 2014). In

2002, measles was announced eradicated (Bartlett, 2014).

Hesitancy

Overall, the public concern, which may be real or perceived, for adverse events

associated with vaccination has increased in the U.S. and has greatly increased the number of

people refusing vaccines (Omer et al., 2009). According to a study performed on the confidence

about vaccines and understanding parents’ perceptions, roughly 83% of parents already fully

vaccinated their children, 11% planned to fully vaccinate in the future, 5% intended to vaccinate

with some vaccines, and 2% reported they would not vaccinate their children with any vaccines.

Public health experts identify the prevalence of hesitations, fears, and misinformation

surrounding vaccines from the media as an indicator of the public confidence levels declining

(Kennedy, et al., 2011).

According to a quantitative survey of primary care pediatricians in Connecticut, more

than 20% of parents reported to have significant concerns regarding the safety of childhood

vaccination (Leib, Liberatos, & Edwards, 2011). These increased rates of reticence and concern

are directly connected with a significant decrease in rates of children vaccination. The most

common reason for non-vaccination, concluded by 69% of parents of exempt children in a case-

control study of knowledge, attitudes, and beliefs was attributed to concern that the vaccine may

cause harm (Omer et al., 2009). The Advisory Committee on Immunization Practices (ACIP)

defines vaccine hesitancy as a method to defer or omit routine vaccines (Domachowske &

Suryadevara, 2013).

According to Domachowske and Suryadevara (2013), vaccine hesitancy dates back to the

1850’s in the U.S. when an anti-vaccination movement began in response to the smallpox

vaccination mandate. Today, hesitancy of vaccination is relatively common while complete

refusal is rare (Domachowske & Suryadevara, 2013). Vaccine hesitancy can be expressed

through parents or caregivers, or by the patients directly. A common rationale for caregiver

hesitancy is parents or caregivers simply believe their child is receiving too many vaccines. In

addition, the media highlighting and reporting supposed vaccine-related adverse events has

greatly lead to the hesitation of vaccines, under-vaccination, or anti-vaccination for some

individuals or caregivers (Flanagan-Klygis, Sharp, & Frader, 2005).

Lawrence and Gostin (2011) point out that several states argue that mandatory

vaccination is an unwarranted interference. Every state offers medical exemptions to children

unable to receive vaccinations due to a medical condition, and all but two states (West Virginia

and Mississippi) allow non-medical exemptions (Wang, Clymer, Davis-Hayes, & Buttenheim,

2014). These non-medical exemptions include religious, philosophical, and/or personal beliefs.

According to the National Immunization Survey (NIS), as a group, vaccination rates are lower in

states as a result of philosophical exemptions over religious exemptions (Domachowske &

Suryadevara, 2013). There are 18 states that make special accommodations in vaccine hesitancy

or refusal for philosophical reasons and 30 states that allow exemptions for children whose

parents claim religious exemptions (McKee & Bohhannon, 2016). According to Kennedy et al.

(2011), 77% of parents claimed to have at least one concern of childhood vaccinations.

Exemption rates for states only allowing religious exemptions were roughly 1% in 2004, and

totaled 2.54% in states allowing philosophical beliefs (Omer et al., 2009). Epidemiologically

speaking, higher exemption rates of vaccination are directly associated with lower vaccination

rates (Wang et al., 2014). This translates to a higher risk of individuals and the general

community contracting and spreading disease.

According to the American Journal of Preventative Medicine, 28% of children were not

in compliance with the ACIP’s suggested standardized vaccination schedule (Luman, Shaw, &

Stokley, 2008). Since not everyone abides by the ACIP’s recommended vaccination schedule, it

is important to understand what drives interest in alternative immunization schedules, or

hesitation to the standardized immunization schedule. Pediatrician’s perceptions of parents more

commonly refusing vaccines is attributed to safety concerns (Flanagan-Klygis et al., 2005).

According to Wheerler and Buttenheim (2013) and the implementation of the Theory of Planned

Behavior, there are various identified components that ultimately lead to vaccination hesitancy

including knowledge, behavioral beliefs, subjective norms, and behavioral intentions. This

study, consistent with prior research also suggests there are many reasons for vaccine hesitancy

and a great variance among vaccination beliefs and attitudes. According to the Vaccination

Confidence Scale derived from the 2010 National Immunization Survey, public trust in health

care providers is a key contributing barrier of vaccination hesitancy (Gilkey et al., 2015).

Hesitation Risks

Mandating vaccination to enroll in school has historically played a contributing role in

vaccine-preventable diseases and in public health throughout the United States (Omer, Pan, and

Halsey, 2006). Children with vaccine exemption or an alternative immunization schedule are at

increased risk for obtaining and transmitting vaccine-preventable diseases (Omer et al., 2009).

Dr. Saad Omer, a global health researcher explains that when the rates of vaccination decline, the

prevalence of disease increases (National Institute of Health, 2016). The risks of under-

vaccination in a developed country like the U.S., is particularly dangerous because of the

international travel that could take place in the local community (NIH, 2016). This could result

in exposure to pathogens and an individual bringing back a disease or diseases and spreading it

into their local community. States permitting personal belief exemptions are directly correlated

with increased vaccine-preventable diseases, and on the contrary, mandated school immunization

is interconnected with low rates of diseases that can be prevented through vaccination (Omer et

al., 2006).

Bartlett (2014) outlines the surveillance data collected from the CDC for selected vaccine

preventable diseases as measles, mumps, polio, rubella, diphtheria, pertussis, and haempophilus

influenza type b. Appendix A: Vaccine Reduction Rates outlines the median annual disease rates

before vaccine availability and recent reports with reduction rates ranging from 68% to 100%.

Hesitancy also puts the community at risk and vital for children and adults who cannot get

vaccinated due to people who have medical contradictions or limitations to vaccination, or those

too young to get vaccinated (Omer et al., 2009). Currently, standardized immunization programs

are amid the safest and most efficient medical interventions (Domachowske & Suryadevara,

2013). Buregyeya et al. (2015) studied motivations and concerns surrounding adolescent

vaccines and concluded that the Ugandan community is open to an adolescent vaccine trial,

however, there is a need for effective communication. Communication should consist of safety

information at a low literacy level so everyone can better understand the importance of vaccines

and even the prevalence of risk. Therefore, it is imperative that health care providers use a

mindful approach to vaccine hesitancy while educating patients using evidence-based data

surrounding vaccination.