Vaccination practices among physicians and their children

doi:10.4236/ojped.2012.23036

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Open Journal of Pediatrics, 2012, 2, 228-235 OJPed

http://dx.doi.org/10.4236/ojped.2012.23036 Published Online September 2012 (http://www.SciRP.org/journal/ojped/)

Vaccination practices among physicians and their children

Michael Martin1, Vahe Badalyan2

1Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, USA

2Department of Gastroenterology, Children’s National Medical Center, Washington DC, USA

Email: [email protected]

Received 1 May 2012; revised 3 July 2012; accepted 30 July 2012

ABSTRACT

The purpose of this study was to identify vaccination

patterns of both general pediatricians and subspe-

cialists with regards to their own children and pro-

jected progeny. A 14 question survey was sent ran-

domly to 1000 members of the Academy of Pediatrics

in 2009. Two categories of questions included 1) how

physicians with children vaccinated them in the past,

and 2) how all respondents would vaccinate a child in

2009. A comparison was made between the answers of

general and specialty pediatricians. 582 valid ques-

tionnaires were received (58.2% response rate) of

which 431 were general pediatricians and 151 sub-

specialists. No statistical difference was found be-

tween general and specialty pediatricians on how they

vaccinated their children up until 2009 (95% vs 93%).

When asked about vaccinating a future child, a sig-

nificant proportion of respondents would deviate

from CDC guidelines, specialists more than general

pediatricians (21% vs 9%). Generalists were more

likely to give a future child Hepatitis A (OR: 3.6; 95%

CI 1.3 - 10.4), Rotavirus (OR: 2.2; 95% CI 1.1 - 4.4),

Meningococcal (OR: 9.9; 95% CI 3.3 - 29.9), and in-

fluenza (OR: 5.4; 95% CI 1.1 - 26.7) vaccines. Spe-

cialists were more likely to postpone MMR vaccine-

tion (OR: 4.4 95% CI 2.3 - 8.6). Safety was listed by

both groups as the most common reason for altering

the recommended immunization schedule. Until 2009,

general pediatricians and pediatric specialists have

largely adhered to ACIP recommendations, but due

to vaccine safety and other concerns, both groups,

albeit a higher percentage of specialists, reported

greater numbers willing to diverge from these rec-

ommendations.

Keywords: Vaccination; Vaccine Adverse Events;

Vaccine Schedule; Pediatricians; Preventable Diseases

1. INTRODUCTION

While parents seek information from many sources, phy-

sicians remain the most commonly relied on resource of

information regarding immunizations [1]. Health care

providers influence the rates of immunization by an-

swering parents’ questions, addressing misinformation,

and ultimately building trust [2-4]. Parents who change

their mind from delaying or refusing vaccines for their

child most often credit the child’s health care provider

for this change [5]. This places the pediatrician in a

unique position to influence vaccination patterns in the

United States.

How pediatricians choose to vaccinate their own

children may provide the closest surrogate for their

actual beliefs on both the necessity and benefits of

immunization and ultimately how they counsel families.

Little is documented, however, on how pediatricians

vaccinate their children overall [6]. One study in 2005

examined how 93% of Swiss physicians followed im-

munization recommendations in that country, but no

duplicate study has been performed in the United States

to date [7]. A number of prior studies have examined

reported acceptance of new vaccines including rotavirus,

but not their acceptance of the overall vaccine schedule

of the Advisory Committee on Immunization Practices

(ACIP) [8-11]. Gust and colleagues in 2008 surveyed

largely family practitioners and a smaller number of

pediatricians and found 11% do not recommend to

parents that children receive all available vaccines [12].

Barriers to acceptance have included safety, cost, reim-

bursement, parental acceptance, as well as a perceived

lack of need for a vaccine [8-11]. It is important to first

identify physicians’ beliefs on vaccines in order to im-

prove the counseling they give to families.

Our study was designed to compare how those physi-

cians involved the most with vaccination, namely general

pediatricians, compared to pediatric subspecialists, who

were less familiar with both vaccine preventable illnesses

and the vaccines themselves, in vaccinating their own

children as well as future progeny. It was surmised that

those persons most familiar with vaccines would be more

likely to fully vaccinate their own children. We also ex-

amined which vaccines were most often not given or

would not be given to future children.

OPEN ACCESS

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 229

2. PATIENTS AND METHODS

1000 web based questionnaires (Figure 1) were sent to a

randomized list of members of the Academy of Pediat-

rics (AAP). An estimated 80% of board certified pedia-

tricians are members of the AAP. Included in responses

were general pediatricians and pediatric subspecialists

currently in the United States. The list of participants

was generated from the AAP member directory and

every 20th name selected alphabetically at random to

participate. If the randomized name did not have a

working email or mailing address, the next name in the

list was used. This occurred in 11 cases. 223 of those

emailed responded to the initial email and 55 responded

to the 2nd email sent out 3 weeks later. The 722 non

responders were sent a questionnaire by mail 3 weeks

following the 2nd email request with a $2 incentive

enclosed in the envelope as well as a stamped envelope

for return of the survey. A total of 657 surveys were

completed in all. All responses were anonymous.

1. You are a:  Male  Female

2. In which state do you primarily practice?

3. Which best describes you?  General Pediatrician  Pediatric Subspecialist  Family Medicine Physician  Other: _____

4. When did you complete medical school?

 After 2004  2000-2003  1990-1999  1980-1989  1970-1979  1960-1969  Before 1960

5. You work: (check all that apply)

 in private practice  in community clinic  at a hospital  in public administration  for the government

 in school of medicine  in the pharmaceutical industry  other professional area

6. Do you have children?  Yes  No (if no, go to question 12)

7. How many children do you have?  1  2  3  4  5 or more

8. What ages are your child(ren)? (check all that apply)  < 2 years old  2 - 4 years old  5 - 10 years old  > 11 years old

9. Did you follow the up-to-date recommended vaccination schedule annually published by the Advisory Committee for Immunization Practices

(ACIP) for all of your children as it was written at the time they were vaccinated?

 Yes (if yes go to question 12 )  No  I did not know or refer to the guidelines

10. If you did not elect to follow the vaccination schedule or followed an alternative schedule, which vaccines did you elect to postpone or not

give? If a vaccine was not available when your child was vaccinated, do not check

it. (check all that apply)

 DTaP  Hib  Prevnar  IPV  Rotavirus  Hep A  Hep B  MMR

 Varicella  Meningococcal (Menactra)  Influenza

11. If you elected to not give a vaccine, or to postpone it, which reasons best describe why. (check all that apply)

 Medical contraindication

 Too many vaccines given at once

 Safety concern

 Vaccine protects against illness that does not present a risk to your child

 Do not believe in efficacy of vaccine

 Other (Please explain):______________________________

12. If you were a “new parent” in 2009-2010, at what age would you give the first dose of MMR to your own children?

 < 18 months old  18 months - 2 years old  3 - 5 years old  6 - 10 years old  11 - 15 years old

 > 15 years old  would not vaccinate

13. If you were a “new parent” in 2009-2010, which vaccines would you NOT give to your own children? (check all that apply)

 None - I would give all of them  DtaP  Hib  Prevnar  IPV  Rotavirus  Hepatitis A

 Hepatitis B  MMR  Varicella  Menactra  Influenza  Other (please specify) ________________________

14. If were a new parent in 2009-2010 and would not give a vaccine, which reasons best describe why. (check all that apply)

 Medical contraindication  Too many vaccines given at once  Safety concern

 Vaccine protects against illness that does not present a risk to the individual  Do not believe in efficacy of vaccine

 Other (please explain)________________________________________________________________________

Figure 1. Survey sent to physicians.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235

230

The 14 question survey was presented on 6 separate

pages as a web survey or a single page as a mailed sur-

vey. Questions were divided into 3 distinct sections: 1)

gathering demographic information; 2) parent physicians

were asked how they vaccinated their own children and

if not following recommended schedules for which vac-

cines and why; and 3) all participants were asked what

vaccines they would or would not give to a hypothetical

new child. In addition to set responses for skipping or not

giving a vaccine, open fields were included to allow for

participants to provide answers not included in the op-

tions given. Web surveys were entered by participants

into Survey Monkey and mailed surveys manually en-

tered into this same program and exported to Microsoft

Excel.

Using standard descriptive statistics, demographic

characteristics of responding participants is shown in

Table 1. Comparisons of baseline demographics and

immunization measures were performed by using

chi-square tests where appropriate. Univariate statistical

analyses were performed for each variable to determine

its relationship to the main independent variable, being a

general pediatrician or subspecialist. Logistic-regression

analysis was used to calculate the adjusted odds rations

(OR) and 95% confidence interval (CI), controlling for

any statistically significant demographic variables that

might act as a confounder. Differences were considered

significant at P < 0.05 and when the 95% CI did not in-

clude 1.0. SPSS statistical software version 18 (SPSS,

Inc., Chicago, IL) was used for the statistical analysis.

3. RESULTS

Of the 1000 surveys sent, a total of 582 were utilized in

our analysis. 75 participants did not fit the categorization

as a pediatric specialist or general pediatrician and were

excluded from analysis. These included 5 family physi-

cians, 33 residents, and 37 persons designating them-

selves as “other” who could not be categorized. Of those

surveys analyzed, 431 were completed by general pedia-

tricians and 151 completed by pediatric subspecialists.

Subspecialists included a wide representation including

pediatric cardiology, urology, neonatology, and even

toxicology. Table 1 summarizes the demographic char-

acteristics of the participants. General pediatricians were

more likely to be female (57%) than subspecialists (40%)

and more likely to work in the outpatient setting (73%

versus 21%).

Table 1. Characteristics of physicians responding.

General Pediatrician (n = 431) Pediatric Specialist (n = 151) Chi squarea P value

Gender (female) 57% 40% 14.06 0.00

Region:

Northeast 25% 18%

Southeast 37% 33%

Midwest 17% 28%

West 21% 21%

9.40 0.02

Type of activity:

Outpatient 73% 21%

Hospital 15% 45%

Government 2% 3%

Medical School 6% 28%

Other 5% 3%

147.57 0.00

Year of medical school completion:

After 2004 17% 6%

2000-2003 13% 14%

1990-1999 32% 27%

1980-1989 20% 25%

1970-1979 11% 20%

1960-1969 4% 8%

Before 1960 2% 0%

23.97 0.00

Has children 78% 85% 2.82 0.09

aUsing two-way tables with measures of association.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 231

Overall, out of 466 respondents who reported having

children, 438 (94%) stated that they followed ACIP

recommendations regarding vaccination. This rate was

slightly higher among general pediatricians (95% vs 93%)

but the difference was not statistically significant. Over-

all rates for individual vaccines were considerably high

ranging from 97% to 100% for both general pediatri-

cians and specialists (Table 2). The lower rate of overall

compliance with the ACIP recommendations is likely

accounted for by differences among which vaccines phy-

sicians elected to skip for their children. One notable

trend, however, was that physicians who graduated from

medical school prior to 1990 were less likely to vaccinate

their own children for rotavirus (OR: 10; 95% CI: 1.1 -

81 P value 0.038).

When asked about how they would vaccinate a poten-

tial child in 2009, larger differences emerged between

general pediatricians and specialists (Table 3). Respon-

dents included both those who have and do not have

children (n = 554). Specialists were found to be less

likely to follow the overall schedule. 41 generalists

(9.9%) and 29 specialists (21%) reported they would skip

at least one vaccine for their future child (Chi square =

0.001). Specifically, generalists in 2009 were more likely

Table 2. Reported vaccination practices of respondents who have their own children.

Generalist (n = 336) Subspecialist (n = 128)P value Adjusted ORa 95% CIb

Followed ACIP recommendation 95% 92% 0.39 0.7 0.3 - 1.7

DTaP 100% 100%

Hib 100% 100%

Pneumococcal 100% 99% 0.79 1.5 0.1 - 27.9

IPV 100% 99% 0.88 1.3 0.1 - 25.9

Rotavirus 98% 98% 0.60 0.6 0.1 - 3.4

Hepatitis A 99% 98% 0.64 1.4 0.3 - 6.9

Hepatitis B 99% 99% 0.55 0.5 0 - 5.5

MMR 98% 100%

Varicella 99% 97% 0.39 1.9 0.4 - 8.8

Meningococcal 100% 98%

Influenza 99% 99% 0.51 0.5 0 - 4.8

aUsing binomial regression model, controlling for the following independent variables: speciality (generalist vs specialist), gender, graduation year (after 1990

or before), living in western states (yes, no), practicing in hospital (yes, no). bOR and CI not calculated if the % of one of the outcomes of the dependent vari-

able was ≤1%.

Table 3. Projected pattern of vaccination of all respondents.

Generalist (n = 416)Subspecialist (n = 138) P value Adjusted ORa 95% CIb

Would postpone MMR until after 18 months 5% 19% 0.00 4.4 2.3 - 8.6

Would not give DTaP 0.5% 0%

Would not give Hib 0% 0%

Would not give Prevnar 0.7% 0%

Would not give IPV 0.2% 0%

Would not give Rotavirus 6% 12% 0.03 2.2 1.1 - 4.4

Would not give Hepatitis A 2% 6% 0.02 3.6 1.3 - 10.4

Would not give Hepatitis B 0.2% 1% 0.83 1.4 0.1 - 28.4

Would not give MMR 1% 1% 0.83 0.8 0.1 - 8.7

Would not give Varicella 1% 2% 0.30 2.3 0.5 - 11.6

Would not give Menactra 1% 9% 0.00 9.9 3.3 - 29.9

Would not give Influenza 1% 3% 0.04 5.4 1.1 - 26.7

Would not give Gardasil 1% 1% 0.57 0.5 0.1 - 4.8

aUsing binomial regression model, controlling for the following independent variables: speciality (generalist vs specialist), gender, graduation year (after 1990

or before), living in western states (yes, no), practicing in hospital (yes, no). bOR and CI not calculated if the % of one of the outcomes of the dependent vari-

able was ≤1%.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235

232

to give a future child Hepatitis A (OR: 3.6; 95% CI 1.3 -

10.4), Rotavirus (OR: 2.2; 95% CI 1.1 - 4.4), Meningo-

coccal (OR: 9.9; 95% CI 3.3 - 29.9), and Influenza (OR:

5.4; 95% CI 1.1 - 26.7) vaccines. Pediatric specialists

reported a stronger desire to postpone future MMR vac-

cination (OR: 4.4 95% CI 2.3 - 8.6), but even 5% of

general pediatricians reported they also would postpone

this vaccine beyond 18 months. Of the respondents who

would elect to withhold at least one vaccine for future

progeny (63 of 70 who actually reported having children),

the most common reason given was “safety” and “too

many vaccines given at once” (Table 4). This pattern

was also seen for those respondents who have children

and elected not to receive vaccines as recommended by

the ACIP (Table 5). Place of work such as in “private

practice” or “for the government” did not demonstrate to

play a role in choosing to vaccinate in either specialists

or generalists.

Table 4. Physicians’ reasons for withholding immunization of future progeny.

Generalist (n = 41) Subspecialist (n = 29)

Medical contraindication 1 (2.4%) 1 (3.4%)

Too many vaccines given at once 4 (9.8%) 3 (10.3%)

Safety concern 12 (29.3%) 12 (41.4%)

Do not believe in efficacy of vaccine3 (7.3%) 2 (6.9%)

Other

“In developed countries Rotavirus is for the most part treatable and I’ve seen some side effects.”

“Rotavirus is negligible in US. More of a problem in 3rd world but vaccine ineffective there.”

“Very low incidence; vaccination not warranted (Hep A).”

“(Gardasil) is not appropriate for USA population, doesn’t remove need for exams, better served in other

parts of world.”

“Not important (Gardasil) to my daughter and presumes promiscuity.”

“Not convinced of need (Hep A).”

“1) A newborn does not need Hep B, 2) Hep A is rare in US, and 3) Rotavirus is too new.”

“Would not bundle vaccines.”

“New to the market, awaiting long term research (Gardasil).”

“Children got H1N1 and protected from disease.”

“No need to introduce another potentially confounding variable until development is clearly normal. Poor

science but good art. (regarding delay of MMR).”

“Feel HAV us unnecessary at that age.”

“Risk is greater than negligible benefit in my family situation (rotavirus).”

“Severity of illness does not warrant vaccination (rotavirus).”

Table 5. Physicians’ reasons for withholding immunization of their own children (those who actually have children).

Generalist (n = 15) Subspecialist (n = 9)

Medical contraindication 1 (6.7%) 0

Too many vaccines given at once 3 (20%) 3 (33%)

Safety concern 3 (20%) 3 (33%)

Do not believe in efficacy of vaccine2 (13%) 1 (11%)

Other

“Wanted to see if [child] got chickenpox and ensure lifetime immunity.”

“Knew baby at low risk [for hepatitis B] at birth, decided to start series at 2 mos checkup.”

“Not in school,limited exposure,able to space them out.”

“Risk exceeds benefit in my family (stay at home parent).”

“Illness itself is usually not severe enough to warrant vaccination (i.e., rotavirus).”

“One child on chemo; other was PDD; other two got everything on schedule.”

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 233

4. DISCUSSION

Until now few studies have examined how pediatricians

in the US vaccinate their own children [6,7]. The results

of this study bridge this gap by confirming that a high

percentage, 94% of respondents, vaccinated their own

children according to ACIP recommendations through

2009 and will likely continue to do so in the future. This

important message of “lead by example” should be

communicated to a public who is increasingly concerned

over the need and safety of vaccines. For those charged

with vaccinating and caring for children, there is a strong

uniformity with respect to their own children in the

actual practice of immunizing as per ACIP recom-

mendations. One of the most common questions asked to

pediatricians is “what would you do with your child?”

This study answers this question.

Pediatric specialists and general pediatricians do ap-

pear potentially poised to diverge further from ACIP

recommendations with future progeny. This trend was

much larger in the subspecialist group. This may be due

to the greater ignorance of subspecialists with regards to

the vaccines and the diseases they prevent. Future studies

might look to correlate the specialty with electing not to

give certain vaccines. Those physicians responding they

would not follow recommendations cited safety as their

largest concern. This parallels the trend of increasing

safety concerns by parents [13-15]. Reasons for safety

concerns given by physicians ranged from claims of vac-

cines being “too new,” of perceived “risk” being “greater

than [the] negligible benefit,” and even a perceived

“risk” in bundling vaccines (Tables 4 and 5).

A significant number of subspecialists did not want to

give hepatitis A (6%), rotavirus (12%), and meningo-

coccal vaccine (9%) moving forward. Comments of

those who would not give hepatitis A included “[I am]

not convinced of the need”, “[I] feel Hepatitis A vaccine-

tion is unnecessary at that age”, “severity of [the] illness

does not warrant vaccination”, and the “risk exceeds the

benefit in my family (stay at home parent)”. Despite

evidence of the enormous cost savings and reduction in

rotavirus morbidity and incidence in the United States,

many physicians in the study appeared to feel that rota-

virus vaccination at the individual level was not appro-

priate in their future progeny [16,17]. It may be that

those physicians who practiced in 1999 are biased

against the rotavirus vaccine having witnessed the recall

of the rotavirus vaccine, Rotashield, due to an associa-

tion with intussusception. Older physicians, those gradu-

ating prior to 1990, in our study demonstrated to be less

inclined to vaccinate with rotavirus compared to their

younger counterparts. With meningococcal vaccine, safety

again was observed to be the major barrier that needs to

be addressed with pediatric specialists. The most signifi-

cant differential between projected immunizations of

children of general pediatricians versus specialists was

with meningococcal vaccination. This possibly reflects

the greater exposure of general pediatricians with the

serious outcomes of the disease caused by this organism.

What is observed from this study is the intent of some

general pediatricians (5%) and a higher proportion of

specialists (19%) to delay the MMR vaccination beyond

18 months of age despite recent increases in incidence of

Measles disease [18]. This is somewhat unexpected

given the time and resources spent to discredit any asso-

ciation between MMR and autism, but it does mimic the

public trend. One physician even goes so far to comment

that there is “no need to introduce another potentially

confounding variable (MMR vaccine) until development

is clearly normal.” This potential trend represents a ma-

jor threat to effectively combating the current rise in

measles. Such physicians may not feel compelled to ar-

gue for timely vaccination with MMR.

Electing not to vaccinate leads to poor outcomes for

many. In a retrospective cohort study spanning 10 years,

unvaccinated children were found to be 22 times more

likely to contract measles and 6 times more likely to

contract pertussis than vaccinated children [19]. In 2008,

the most measles cases since 1996 occurred. 112 of a

total of 131 cases were unvaccinated or had unknown

vaccination status [20]. In 2009, approximately 0.6% of

children between 19 and 35 months received no vac-

cinations and represents an increase from 0.4% from

2006 [18]. Despite these trends, delaying MMR vac-

cination based on our findings may increase among pedi-

atric clinicians.

Our results did show some methodological limitations

necessitating caution in interpreting them. Recollection

bias may have influenced answers that relied on phy-

sicians’ recall of past vaccine practices. Also, answers

for a hypothetical child, may not necessarily translate

into actions once a physician has an actual child. This

survey drew from a pool of pediatric providers who were

far more likely to be interested in vaccine issues as

immunization of all children is a primary stated goal of

the AAP. This suggests that compliance of the survey

respondents in vaccinating their own children according

to ACIP guidelines will be higher than for the general

population of pediatric providers in the US. The survey

also did not address whether responders were actively

charged with vaccinating patients. It is not known

whether those working “for the government” or “in a

school of medicine” actually vaccinate children in their

workplace. It is also possible that questionnaires were

sent to pediatricians who were parents of the same child

although no physicians bearing the same last name who

completed the questionnaire were located in the same

state. Unfortunately, from the database it was not possible

to elicit relationships of physicians surveyed.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235

234

While most pediatricians and pediatric specialists

(95% and 93%) have adhered to the recommended ACIP

vaccination schedule up until 2009, a potential for change

emerged with 10% of pediatricians and 21% of pediatric

specialists claiming they would not follow the recom-

mendations for future progeny. Despite their education,

physicians in this study expressed concern over the

safety of vaccines. This study points to the need to focus

on education efforts, including safety data, for those

particular vaccines physicians displayed the greatest

concern over including hepatitis A, rotavirus, meningo-

coccal, and measles. Pediatric specialists should be in-

cluded in this education as they have the greatest

concerns, may be the most removed from the diseases

protected by the immunizations, but also care for some

of the most vulnerable populations. It has been shown

that the more convinced physicians are of the benefits of

vaccines, the more likely they are to immunize their

patients [21-23].

Researchers might look to correlate whether patients

of physicians who choose not to follow current recom-

mendations are indeed more likely to also not follow the

published schedule. Continued control of communicable

disease will rely on the success of efforts to educate the

public and physicians. Future study should thus focus on

how to best address safety concerns which presents the

greatest threat to sustained high vaccination level.

5. ACKNOWLEDGEMENTS

An educational grant for this study was provided by Inova Health Sys-

tems.

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