In “Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey,” Kempe et al1  investigated parental attitudes regarding vaccines. They queried a representative sample of parents using a modified survey that was devised by the World Health Organization. Half of the >4000 parents surveyed responded. Six percent were hesitant about the receipt of routine vaccinations and 26% were hesitant about the receipt of influenza vaccines; however, a similar proportion of participants (39%) had vaccine safety concerns. More participants strongly agreed that routine vaccines were effective (70%) when compared to influenza (26%). The study results are likely generalizable because they originated from a nationally representative sample and measured vaccine hesitancy by using a validated scoring system. One limitation of the survey was its online-only administration, which potentially eliminated parents without Internet access.

Why are parents so hesitant about influenza vaccines? The authors propose that it is the result of yearly reports of low vaccine effectiveness from surveillance networks and the withdrawal of the live attenuated vaccine for poor effectiveness several years ago. Additionally, more than one-third of parents have vaccine safety concerns. From the pragmatic standpoint of improving immunization rates and disease control, determining the correct evidence-based messaging to counter these perceptions is the next logical step. Communications should be focused on the burden of influenza in children, rebranding influenza vaccine as a “routine” childhood immunization, reassurance on influenza vaccine safety, and discussion of the efficacy of influenza vaccine in preventing severe disease.

Unaware of the burden of disease and severity, parents may dismiss influenza vaccination. However, influenza causes severe disease in children,2  with high rates of outpatient visits and hospitalizations. In the 2017–2018, 2018–2019, and the current 2019–2020 influenza seasons in the United States, there were 188, 144, and 169 pediatric deaths, respectively.3  When discussing the importance of flu vaccine, providers can say, “Influenza can cause serious disease in children, including hospitalization and death.”

Influenza vaccine should be viewed as a routine childhood immunization, and a presumptive approach should be used when discussing influenza vaccine administration.4  Instead of saying, “Is it okay if your child receives the flu vaccine today?” providers could state, “Today, your child will receive their recommended influenza vaccine.” Because families consider their child’s primary care provider to be a trusted source of information, this presumptive approach is generally successful.4 

Overwhelming evidence demonstrates that influenza vaccines are safe, with nearly 170 million vaccine doses safely given in the United States during the 2018–2019 influenza season.5  Vaccine safety is carefully evaluated in clinical trials during vaccine development and continues through population-based surveillance networks postlicensing.6,7  Data from these networks are reassuring.8  Despite these data, parents still express significant concerns about vaccine safety.1  When parents refuse the influenza vaccine, physicians should inquire why they are refusing the vaccine. If parents cite safety concerns, physicians can communicate the following: “Flu vaccine is one of the most frequently administered vaccines, with over 150 million doses given each year in the United States. Numerous studies have demonstrated that it is safe and effective.”

Finally, providers can discuss the impact of influenza vaccines on disease prevention. Annual influenza vaccine effectiveness can be more accurately measured by its impact on preventing hospitalization, severe illness, and death. Influenza vaccination has repeatedly been shown to prevent the spread of influenza and reduce the severity of illness.9,10  Children who receive influenza vaccine are less likely to be hospitalized for influenzalike illness than unimmunized children.11,12  When reports of vaccine efficacy are released each year, these data should be taken within the context of preventing severe illness rather than simply commenting on the matching of circulating influenza strains. Even in the years when there is a poor match, the vaccine is impactful. For example, during the severe 2017–2018 influenza season, when overall vaccine effectiveness was 38%, it was estimated that influenza vaccination prevented 7.1 million illnesses, 3.7 million medical visits, 109 000 hospitalizations, and 8000 deaths in the United States. Vaccination prevented 41% of expected hospitalizations among young children (6 months–4 years).10 

As Kempe et al1  note in this issue of Pediatrics, parental hesitancy with respect to flu vaccine is more prevalent than hesitancy about routine childhood immunizations. The results of this survey suggest that when communicating about flu vaccine, it is important to remind parents that flu can be severe in children and to highlight the efficacy and safety of flu vaccine. Although researchers continue work to improve the efficacy of influenza vaccines, vaccines remain a powerful tool to prevent influenza.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-3852.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Edwards reports consultation for Merck, Bionet, and International Business Machines; membership of data safety and monitoring boards for Sanofi, X4 Pharmaceuticals, from Seqirus, Moderna, and Pfizer; Dr de St. Maurice has indicated he has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE Dr Edwards reports grants from the Centers for Disease Control and Prevention and the National Institutes of Health; consultation for Merck, Bionet, and International Business Machines; and membership of data safety and monitoring boards for Sanofi, X4 Pharmaceuticals, from Seqirus, Moderna, and Pfizer. Dr de St. Maurice has indicated he has no financial relationships relevant to this article to disclose.