Subtle forms of vaccine hesitancy affecting children and adolescents are unreasonable and risky

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Vaccine refusal and hesitancy have clear adverse effects on the nonvaccinated individual as well as on the community. Related research has been performed largely in the general pediatric population. Two studies have focused their lenses on subtle forms of vaccine hesitancy, in special groups—children with Down syndrome and the general adolescent population. In this volume of The Journal Langkamp et al administered the Parental Attitudes about Childhood Vaccines Survey (PACV) (a validated tool for the general pediatric population) to 55 parents of children ≤8 years of age attending the Down Syndrome Clinic at Akron Children’s Hospital and matched results with their child’s immunization record to assess association with up-to-date status for standard vaccines at 19 months of age. In all, 7% of parents refused all vaccines, and 18% considered themselves as vaccine hesitant, but almost one-half reported that they were concerned that their child would have a serious side effect, thought it better to have fewer vaccines at the same time, and had decided not to have their child receive an injection for reasons other than illness or allergy. Not surprisingly at 19 months, only 58% of children with Down syndrome were up to date for all 8 vaccines and only 31% also had had no delays. The percentage of children up to date declined with higher PACV scores. Both percentages of delayed and non-completion are substantially higher than in the general population and in some children studied with other chronic conditions, and are especially disconcerting in Down syndrome patients who have undo susceptibility to severe vaccine-preventable disease.

The study by Robison et al in The Journal of Pediatrics: X used Oregon’s electronic immunization registry ALERT IIS to assess the prevalence in >240 000 adolescents receiving only a single vaccine injection per visit at ≥9 years of age and its relationship with initiating and completing a valid human papillomavirus (HPV) vaccination series. The study also probed the relationship of earlier injection limitation at ≥4 years of age with later injection-limiting behavior and HPV vaccination. In accordance with school requirement of Tdap receipt for 7th grade entry, 93% of all adolescents had received Tdap, but only 79% had received MenACWY and 70% had initiated the HPV series. For adolescents who received multiple injections on at least one visit at ≥9 years of age, 61% completed the HPV series compared with only 8% of injection-limiting adolescents. Data further showed that injection limitation at an earlier age (likely parent choice) was associated with similar behavior at ≥9 years of age (likely patient choice or parent choice/acquiescence). When a second visit occurred for an injection-limiting teen, MenACWY rather than HPV was chosen as the next single injection, reducing further the likelihood that the 2 required additional visits to complete HPV series would occur.

There is no lack of safety or excess rate/severity of side effects in children with Down syndrome. There is no superior immunologic or safety basis, or evidence of psychological benefit, for separation of vaccines or injections. There is evidence from these 2 studies that such practices are associated with excess risk of achieving vaccine protection. Considering that for adolescents multiple highly beneficial vaccines now are standard recommendations, and that there is falloff of healthcare visits through teen years, the unreasonable practice of limiting injections per visit especially jeopardizes the age-sensitive, cancer-prevention opportunity of HPV vaccination. These studies expand and reinforce what should be every provider’s strong recommendation to immunize all children and adolescents, on time, at all eligible encounters, and without limiting vaccines or number of injections per visit.

Article pages 64 and at J Pediatr: X 2020;3:100024

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