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Improving Vaccine Compliance in the Pediatric Population

Michael Overholt, Brooke Baker, Natalie Dunlap, Kaitlin McFarland, and Alexandria Moreschi

Youngstown State University

NURS 3749: Nursing Research

Dr. Kim Ballone

April 8, 2020

Abstract
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The purpose of this research was to examine which factors contribute to achieving significant

influenza vaccine coverage among those aged 0-18 years. Our literature-based research was

drawn from several surveys and experimental studies. These studies looked at the effects that

both school-based immunization clinics and physician recommendations had on vaccine

coverage for this population, as well as the reasons parents gave for their hesitancy in

vaccinating their children. It was found that school-based immunization clinics were effective in

increasing vaccination rates in school-aged children. However, it was found that presenting

parents with educational materials or a physician’s recommendation alone was not sufficient to

improve these rates; in fact, in some cases rates surprisingly decreased. One study also presented

evidence showcasing the global impact anti-vaccination can have on herd immunity and the total

population’s health. Overall, the research showed that there are pathways that exist to overcome

vaccine hesitancy, and health care workers have a responsibility to be advocates for vaccination

in the pediatric population.

Introduction

Since their inception, vaccinations have drawn considerable debate and controversy.

Reasons for abstaining from receiving vaccines range from personal religious beliefs, to the
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notion that vaccines are directly linked to autism, and to the overall opinion that vaccines will

simply cause more harm than good. In the modern era, the ease and accessibility of retrieving

information, but more namely misinformation, has largely contributed to a resurgence of vaccine

hesitancy.

One vaccine in particular that has brought about such contention is the influenza vaccine.

The CDC currently recommends that everyone six months of age or older who does not have any

contraindications should receive the influenza vaccine yearly. However, it was reported that only

62.6% of children ages 6 months to 17 years received the flu vaccine during the 2018-19 flu

season. A lack of coverage exposes those who are vulnerable, particularly those aged 6-59

months and those with compromised immune systems, to not only contracting the virus, but also

to the serious and sometimes fatal complications that can result. Therefore, the following

question was asked: In order to improve routine immunization compliance, which interventions

can increase vaccination coverage as compared to the current situation?

The Problem

Vaccines are largely a victim of their own success. Today there are very few people alive

that can recall with sufficient memory a polio iron lung ward. That’s because in 1952 Jonas Salk

invented the first successful polio vaccine. People came from miles around to healthcare centers,

and waited in long lines for the opportunity to receive this vaccination. Within a generation rates

of infectious polio plummeted. In its day the polio vaccine was considered a triumph of modern

medicine. Today vaccines are viewed with skepticism. This is best evidenced by the 38 recent

measles outbreaks in America between 2001-2008. “Lack of personal experience with measles

has led certain parents to focus on vaccine-adverse events and to refuse measles vaccination”
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(Gust et al., 2004; Sugerman et al.) To examine the full implications of this behavior, we must

dive into the concept of herd immunity. ‘Herd immunity’ means that “the risk of infection among

susceptible individuals in a population is reduced by the presence and proximity of immune

individuals” (Fine et al., 2011: 911). The success of herd immunity is dependent on maintaining

a threshold-proportion of immune individuals that will suppress the transmission and

proliferation of the virus in question. The essential idea here is that it is impossible to transmit

polio if you are immune to it. In the case of polio the mass immunization of millions of people

world-wide in just a few short years created a situation where the majority of the global

population had acquired immunity from the virus. In 1952 the year the vaccine was invented

60,000 American children became infected with polio, 3,000 of those children died. Contrast this

with last year's global total of 23 cases. It is clear that vaccines work. Despite this fact

vaccinations for influenza, MMR and others have been undercut in recent years by the decision

of parents to refuse vaccines, increasing the chances for individual infection, and leading to

potential outbreaks. “In many communities, vaccination rates, particularly for children, have

dropped below thresholds necessary to maintain herd immunity.” (Ropiek 2013) Now these

communities face the potential outbreak of a preventable disease not only for those who are

unvaccinated but also for those who are too young to be vaccinated or are unable to be

vaccinated due to immunosuppression. For example “Pertussis sickened more than 9,000

Californians in 2012, and killed ten infants, the worst outbreak in 60 years. This followed a

decline in DTaP vaccination rates in some communities in California for the previous several

years.” (Ropiek 2019). This example of pertussis gets to the heart of the problem, individuals

who are unvaccinated place others at risk.

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One major way that can promote getting vaccines in children is providing information to

the parents. In this study from Klifa, it shows how many parents came in and got the influenza

vaccine for their children that have other health problems, specifically idiopathic nephrotic

syndrome. The study was out of 57 patients, and only 14 children got the follow up

recommended vaccines, while the other 43 did not receive it. When discussing this study, it was

shown that many parents were misinformed about getting this follow up vaccine, and what they

were supposed to do with their child’s prescriptions. The best way to better promote getting

influenza vaccines is having directions and providing information to the children, along with

their parents. Looking at this specific age group, zero to eighteen years old, one of the greatest

ways to get them to get their influenza vaccine is by their parents. When parents are informed

about the benefits and understand doctors prescriptions for their children, the better they will be

at getting their children their vaccines. (Klifa 2019).

Not only can we inform parents about these vaccines, this can help with the many fears

that parents have about vaccines. From the study of Glasper, it shows the fear and the perception

of the history of getting vaccines. The fear of getting vaccines has been around since they were

invented. The Royal Society for Public Health demonstrates that fear is the major side effect and

reason why parents do not want their children to be vaccinated. From this fear, it is leading to

less vaccines administered, which then causes a lower herd immunity. Having a low herd

immunity then puts the population at risk for getting these diseases that people who did not get

vaccinated then have a higher chance of getting the diseases. WHO reports that there are twenty

million children worldwide that are either not vaccinated or undervaccinated. The best way to

decrease this fear is contributing solutions that show what information is false. Many anti-

vaccinators spread information that is false, that many people tend to believe is lowering the
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vaccination averages. Most of this false information is spread through social media, which is not

a reliable source to believe when related to medical conditions. The best way to stop this spread

of false information. This is a main priority for health care workers, school administration and

news outlets to be reporting education about vaccinations and making sure that this information

is overcoming the false information about vaccinations (Glasper 2019).

Research conducted by Hilton was done to see how doctors are responding to this anti-

vaccination movement and how they are using methods to educate parents about vaccinations. It

shows that anti-vaccination is a top ten threat to public health, along with the main issue from

this being misinformation about what vaccines are and what they can cause. Not getting

vaccinated causes a greater risk of getting diseases, such as influenza, measles, rubella, and

more. Doctors provide the biggest support in promoting and educating parents about the

importance of vaccinating their children. They have to remember that using statistics and data

does not have much effect when it comes to educating parents and families; personal stories and

making the information relatable to them have the most effect. Having this information presented

to families can then help overrule the misinformation that is created and can lessen the vaccine

hesitancy and refusal from parents (Hilton 2019).

Do vaccine clinics at schools raise vaccination rates? This is the question Szilagyi et al.

(2019) attempts to answer in their research article focused on school-located influenza

vaccinations. Of all schoolchildren in the United States only half of them receive the influenza

vaccine, and although school-located Influenza vaccinations may raise the rate at which children

receive this vaccination, the implementation of a program designed to accomplish this is

challenging. The researchers in this experiment compared two school programs designed to raise

influenza vaccination rates and ultimately split the participating schools into three groups. There
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was a control group with no school-located influenza vaccination and no parent reminder or

education. One group consisted of a parent reminder and educational messages sent to parents

from schools which is classified as a low-intensity intervention, and the other being a

combination of reminder and educational messages plus school-located influenza vaccination

clinics which is a high-intensity intervention (Szilagyi et al., 2019).

Among the population of 24,832 children, using multivariate analyses which controlled

for vaccination in prior seasons, children in the reminder/education plus school-located influenza

vaccination clinic schools had higher vaccination rates, but children in the reminder and

education-only schools had lower rates than children in the control group schools. The

researchers concluded that parent reminder and educational messages sent to parents from

schools combined with school-located influenza vaccination clinics raise vaccination rates, but

parent reminder and education alone does not (Szilagyi et al., 2019).

Szilagyi et al. (2016) again conspired to produce research on school-located influenza

vaccinations, this time with a randomized trial. The objective of this research was to assess the

impact of offering school-located influenza vaccination clinics using both web-based and paper

consent upon overall influenza vaccination rates among elementary school children. To do this a

cluster-randomized trial stratified by suburban and urban districts was completed. 44 elementary

schools were randomized, selected to be pairs of schools within districts, and allocated schools to

school-located influenza vaccination clinics versus the usual care as the control group. Parents of

children at school-located influenza vaccination schools were sent information and vaccination

consent forms via email, backpack fliers, or both depending on school preferences regarding

school vaccine clinics. The results found that children in school-located influenza vaccination

clinic schools had higher influenza vaccination rates than children in control schools county-
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wide and in suburban and urban schools. A multivariate analysis controlling for age, grade, and

vaccination in previous seasons was performed confirming bivariate findings. Among parents

who consented for school-located influenza vaccination clinics, nearly half of those notified by

backpack fliers and four-fifths of those notified by email consented online. School-located

influenza vaccination clinics raised seasonal influenza vaccination rates county-wide and in both

suburban and urban settings. School-located influenza vaccination clinics did not substitute for

primary care vaccinations in suburban settings where pediatricians often preorder influenza

vaccines but did substitute somewhat in urban settings (Szilagyi et al., 2016).

Conclusion

In his article regarding immunizations, Professor Alan Glasper, from the University of

Southampton, remarks that, “…public fear of immunization is as old as the history of vaccination

itself” (p. 588, 2019). To highlight this point, he refers to an incident that occurred in 1974. A

study had been released that suggested a possible link between the pertussis vaccine and

neurological complications. When this study was made public, there was a sudden, sharp decline

in the number of pertussis vaccinations being given. Unfortunately, this low vaccine coverage

resulted in a massive outbreak of pertussis throughout England and Wales (Glasper, 2019). Since

there was such hesitancy toward the vaccine, it created an environment where the bacteria could

thrive. Very few people were protected from the bacteria which produced a low herd immunity.

Since the outbreak, further studies have been conducted which debunk the supposed link

between the vaccine and neurological complications (Glasper, 2019). This is just one example of

an outbreak that could have been avoided by receiving a routine vaccination.

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Despite the consequences of vaccine non-compliance, there are still many people today

who are hesitant or downright opposed to vaccinations. This fear has developed into an anti

vaccination movement that has become a serious threat to public health (Hilton, 2019). It is

important to remember that this is a global issue-nearly every country is facing the vaccine

dilemma. In Kenya for example, the Catholic Bishops are pushing for a boycott of the polio

vaccine. Meanwhile in Afghanistan, the Taliban is also using their influence to stop the use of

this vaccine (Glasper, 2019). There are also countless parents worldwide who are choosing not to

vaccinate their children for one reason or another. The World Health Organization (WHO) states

there are approximately 20 million children worldwide who are either under-vaccinated or who

have never received a single vaccination (Glasper, 2019). It is abundantly clear this anti-

vaccination movement is influencing parents’ decisions about their children’s health.

Considering the fact that vaccine hesitancy is one of the top ten threats to global health, it

is vital to take steps to reverse this dangerous trend (Hilton, 2019). There is a lot of

misinformation circulating regarding vaccines and many people are buying into this propaganda.

The best way to combat this is through education. The Royal Society for Public Health (RSPH)

recognizes this need and proposes that vaccination education should be a priority for all

healthcare workers (Glasper, 2019). While some parents and individuals want to know the

statistics regarding vaccinations, this approach doesn’t work with everyone. As far as childhood

immunizations, pediatricians play a very important role in educating families (Hilton, 2019).

When a pediatrician is willing to spend extra time with parents and share from their own

experience in the field, it can make a difference in the way parents view immunizations. It is also

important to note the difference between someone who is vaccine hesitant and someone who is

vaccine resistant (Hilton, 2019). Oftentimes it just takes a nurse or a doctor who is willing to sort
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through information and clear up misconceptions with a family to help them see the importance

of vaccines. As education continues to be a priority in healthcare, the evidence strongly supports

that vaccination compliance will increase accordingly.

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