Recent studies have described an increase in parental hesitancy regarding vaccines as well as increases in parental adoption of vaccine schedules that delay or limit receipt of recommended vaccines. This study quantifies potential prevalence and trends in alternative schedule compliance by measuring consistent shot-limiting in a metropolitan area of Oregon.
Retrospective cohort analysis using the Oregon ALERT Immunization Information System to track children born between 2003 and 2009 in the Portland metropolitan area. Joinpoint regression was used to analyze prevalence trends in consistent shot-limiting during that time period. The 2007–2009 Haemophilus influenzae type b vaccine shortage and increased availability of combination vaccines were also examined for their effects on shot-limiting rates.
A total of 4502 of 97 711 (4.6%) children met the definition of consistent shot-limiters. The proportion of consistent shot-limiters in the population increased from 2.5% to 9.5% between 2006 and 2009. Compared with those with no or episodic limiting, consistent shot-limiters by 9 months of age had fewer injections (6.4 vs 10.4) but more visits when immunizations were administered (4.2 vs 3.3). However, only a small minority of shot-limiters closely adhered to published alternative schedules.
The percentage of children consistently receiving 2 or fewer vaccine injections per visit between birth and age 9 months increased threefold within a 2-year period, suggesting an increase in acceptance of non–Advisory Committee on Immunization Practices vaccine schedules in this geographic area.
We appreciate the work that Robison et al. have done in conducting their study entitled "Frequency of Alternative Immunization Schedule Use in a Metropolitan Area."[1] Their work sheds light on the growth of this problem in Oregon. We have every reason to believe that such growth is occurring elsewhere at similar rates across the country. As practicing pediatricians, we certainly have experienced parents' requests for something other than what the ACIP, the AAP, and the AAFP recommend in the form of the harmonized schedule for routine childhood vaccination.[2]
However, we think that we do a disservice to the science and practice of vaccination when we refer to these deviations as "alternative immunization schedules." The term gives the requested delays and omissions the imprimatur of acceptability, but these pseudo-schedules lack the years of rigorous study of both the epidemiology of the disease and the efficacy and safety of the vaccines given in the schedule as proposed.[3] These pseudo-schedules are instead euphemisms for avoidance and delay. They leave the child unprotected often during that child's highest period of risk, and in most cases increase the risk for other children. These risks have been carefully documented where possible.[4,5,6,7]
The adjective "alternative" suggests that the schedule has a rational or empirical basis. "Alternative" makes the schedule sound scientific and well-thought-out. When we use the term "alternative immunization schedule," we are granting a form of respect to that "schedule" that it does not deserve. Even calling it a "schedule" is a concession. These are not "schedules;" these are "delaying and avoiding tactics." As Robison et al. show, few parents who initiate such "plans" actually stick with them.[1]
We should take caution with the term "shot-limiter" as well. The ACIP, the AAP, and practicing pediatricians--as well as our patients' parents--applaud and welcome the availability of combination vaccines as a great advance toward limiting the number of needle pricks a child receives. We are all "shot-limiters," but most of us would not consider ourselves "shot-limiters" as defined in this article.
The terms we choose to use affect the direction of our conversations about vaccination. We need more accurate descriptors. Here are some to consider in place of the word "alternative." Consider "pseudo-," "faux," "unproven," "unstudied," "untested," "unvetted," "unsupported," "illogical," and "improper." Perhaps we should call such a proposal to delay and cherry-pick vaccines as an "intentionally under-vaccinating tactic" or an "extended-risk device."
Let's be more careful with our words, their meanings, and our patients.
1. Robison SG, Groom H, Young C. Frequency of Alternative Immunization Schedule Use in a Metropolitan Area. Pediatrics 2012; 130:32- 8
2. Recommended Immunization Schedules for Persons Aged 0 Through 18 Years -- United States, 2012. MMWR 2012;61:1-4
3. Offit PA, Moser CA. The Problem with Dr. Bob's Alternative Vaccine Schedule. Pediatrics 2009;123(1): e164-9.
4. Salmon DA. Haber M, Gangarosa EJ, Phillips L, Smith N, Chen RT. Health consequences of religious and philosophical exemptions from immunization laws: Individual and societal risks of measles. JAMA. 1999 July 7; 282(1): 47 -53.
5. Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE. Individual and community risks of measles and pertussis associated with exemptions to immunizations. JAMA. 2000 Dec 27: 284(24): 3145-50.
6. Jansen VAA, Stollenwerk N, Jensen HJ, Ramsay ME, Edmunds WJ, Rhodes CJ. Measles Outbreaks in a Population with Declining Vaccine Uptake. Science 2003;301 (5634): 804.
7. Sugerman DE, Barskey AE, Delea MG, Ortega-Sanchez IR, Bi D, Ralston KJ, Rota PA, Waters-Montijo K, LeBaron CW. Measles Outbreak in a Highly Vaccinated Population, San Diego, 2008: Role of the Intentionally Undervaccinated. Pediatrics 125 (4): 747-55.
Conflict of Interest:
Robert M. Jacobson, M.D., serves as a member of a Safety Review Committee and a Data Monitoring Committee regarding two Merck vaccines. He has recently served as a Principal Investigator regarding a Novartis vaccine and a Pfizer vaccine. Aaron S. DeVries, M.D., M.P.H., Minnesota Department of Health, has no competing interests.