The consternation and confusion mean pediatric practices are increasingly facing an ethical dilemma: Should they drop unvaccinated families — and not accept new ones who decline to vaccinate — to protect other children in their waiting rooms?
Or do they stick with the holdouts and hope they eventually convince them to change their minds — but potentially put newborns or other immune-compromised patients in waiting rooms at risk of infection?
“I do try to talk to families about how necessary these vaccines are, but it’s getting harder, and we spend more time doing that,” said Dr. Jeffrey Stockman, the lead physician at Cape Ann Pediatricians in Gloucester.
Stockman has had a policy for decades requiring his patients to be vaccinated. But in the past year, he said, he has had to drop five or six families because they repeatedly declined, numbers he has not seen before.
“I have to protect other patients in my office, too,” he said.
While the percentage of Massachusetts kindergarteners whose parents claimed a medical or religious exemption against vaccinating their children is tiny, it is notable, given the state’s solid history of supporting science and health care. The percentage has been steadily growing and now is the largest it’s been in a decade — 1.4 percent — state numbers show.
Amid a swirl of misinformation and vaccine skepticism espoused by Robert F. Kennedy Jr., the nation’s health secretary, recent polls paint mixed pictures of the anxieties American parents are feeling about vaccinating their children.
Fewer Americans today consider childhood vaccines important, according to a recent Gallup Poll, with 40 percent saying it is extremely important for parents to have their children vaccinated, down from 58 percent in 2019.
Yet a Kaiser survey last month found large majorities of parents, roughly 90 percent, have positive views of some long-standing childhood vaccinations, such as for measles, mumps, and rubella and polio, saying it’s important for children in their community to receive them.
Confidence in seasonal vaccines for flu and especially COVID is far lower, with 56 percent saying it’s important for children in their community to get a flu shot and just 43 percent saying that for COVID.
Dr. Wayne Altman, who co-owns a family medicine practice in Arlington and is vice president of the Massachusetts Academy of Family Physicians, said he does not believe in discharging patients for declining vaccines, calling that “medical NIMBY-ism.”
“I haven’t solved any problem by kicking anyone out of my waiting room and my practice. I have just shifted it to someone else,” he said. “It doesn’t seem like an ethical thing to do.”
Altman said some reluctant parents, but certainly not all, eventually decide to vaccinate, given time and respectful conversations.
To help lower the risk of infecting other vulnerable people who may be inadvertently exposed to an infectious, unvaccinated child, Altman last year bought high-quality air filters for his waiting room and every exam room, and they are kept on all day.
“I don’t know that they are foolproof, but they help,” he said.
At Boston Community Pediatrics, an unusual nonprofit private practice mostly supported by philanthropy, and with a majority of its 1,700 patients insured by MassHealth, Dr. Robyn Riseberg said her team is grappling with many more questions from parents now compared with a few years ago.
“We are seeing more mistrust of the health care system and mistrust of pediatric health care,” Riseberg said.
“What we like to tell people upfront is that we firmly believe in vaccines, and it’s a part of our practice,” she said. “So, someone who isn’t interested in being vaccinated, it would not be a right fit for them because this is something we will talk about in every visit.”
The practice, which features unhurried 30- to 60-minute-long routine visits, requires patients to receive the traditional childhood immunizations and recommends, but does not require flu and COVID shots. Many parents decline those two shots for their children, Riseberg said.
Health providers are also fielding a lot more questions about vaccines in one of the largest networks of pediatricians in Massachusetts, the Pediatric Physicians’ Organization at Children’s, which serves about 450,000 children across 110 locations. The network doesn’t have a blanket policy about vaccinations, allowing each practice to set its own.
The network in the past year started offering education sessions to providers to help them better understand the onslaught of mixed messages parents of young children may be walking in with.
“Unless you are a parent of young children today, you may not know the many avenues that people get their information from, and the many things they might be hearing before they have a chance to talk to the trusted pediatrician or pediatric nurse practitioner,” said Dr. Michelle Lock, the network’s chief medical officer.
For instance, a number of social media influencers, many targeting women and especially mothers, have been dispensing “overtly conspiratorial anti-vaccine messaging and used it to sell products and services they profited from,” researchers at the University of Washington found.
Amid a chronic shortage of primary care providers, including pediatricians, parents who choose not to vaccinate their children say they are finding it harder to find care. Candice Edwards, executive director of Health Action Massachusetts, an organization that advocates to maintain vaccine exemptions for children in schools, said in a statement that some of its members have been denied ongoing medical care because of their vaccination choices.
“Some are guided by sincerely held religious beliefs, yet are denied care under blanket practice policies that equate their decisions with hesitancy or refusal,” Edwards said. “In effect, these policies create discriminatory barriers for families of faith seeking medical care. Others simply wish to delay certain vaccinations until their children are school-aged or decline only a limited subset.”
A decade ago, as pediatricians faced growing parental pushback on vaccines, the American Academy of Pediatrics changed its position against dropping patients who refuse to vaccinate. Instead, it said dismissal was acceptable “only after careful consideration of the situation, transparency with parents about the risks to their child, and openness about practice policies.”
Dr. Sean O’Leary, a Colorado pediatrician and chair of the committee on infectious diseases at the academy, said a 2019 survey of members found that even then, when members spoke with parents who had substantial vaccine concerns, 53 percent said they spent between 10 and 19 minutes of a typical 15-minute visit discussing that.
“These conversations bring burnout instead of booster shots; 46 percent of pediatricians found their work less satisfying as a result of needing to discuss vaccines at length,“ O’Leary wrote in a 2020 article in the Journal of Pediatrics.
The academy has not surveyed members since, but O’Leary said anecdotally they are hearing of more practices not accepting non-vaccinators.
“I have heard from practices going along with a few families that refuse vaccines, and then a practice near them adopts a new policy requiring vaccinations, and all of a sudden, they have an influx of families that do not vaccinate their kids,” he said.
O’Leary said the growing number of practices that dismiss patients may paradoxically increase the risk of disease outbreaks.
“As increasing numbers of unvaccinated patients cluster in practices tolerant of vaccine delay or refusal,” he said, “the risks of vaccine-preventable diseases in those practices and communities only increase.”
Kay Lazar can be reached at [email protected] Follow her @GlobeKayLazar.
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