A pediatric COVID-19 vaccine was given an emergency use authorization by the U.S. Food & Drug Administration (FDA) in late October 2021. With AAP data indicating that over 6.5 million children have tested positive for the virus since the start of the pandemic, the introduction of the vaccines allows pediatricians to offer a life-saving and protective healthcare service for children during a period of uncertainty and turmoil for children’s academic and home lives. An expression of vaccine hesitancy is a crucial moment in the relationship between families and pediatricians, where physicians can lean on years of trust and support to help get kids the healthcare they need.
Vaccine Hesitancy is Not a Surprise
As early as April 2021, physicians at an AAP town hall event reported that they anticipated vaccine hesitancy to be a key obstacle in the mission to vaccinate American children against SARS-CoV-2, the virus that causes COVID-19. Panelist Dr. David Kimberlin even suggested that a potential challenge for administering the vaccine was not a parent’s or patient’s disinclination towards the shot, but ambivalence towards it. “Now, we need to find people that maybe are hesitant but also may be just a bit indifferent. They’re fine to get the vaccine, they just don’t want to … go to the trouble to do so.”
In early November, 2021, the CDC and AAP reported that 58% of 12 to 17 year-olds have received at least one dose of the COVID-19 vaccine, and 49% of 12 to 17 year-olds are fully vaccinated. For the remainder of 12 to 17 year-olds and now the majority of 5 to 11 year-olds who are newly eligible, conversations around vaccination will remain top of mind for pediatricians for the foreseeable future.
There are several ways to address vaccine hesitancy, but perhaps the most crucial tool in a pediatrician’s kit is patience -- the relationships between pediatricians and parents are important ones, but parents may need time to come to accept the need for a COVID-19 vaccination for their child for a myriad of reasons.
3 Types of COVID-19 Vaccine Hesitancy
“With children, we find parents are generally more cautious than they are when it comes to even getting the vaccine themselves.” The Kaiser Family Foundation for NPR
Families are apt to react to the news of a pediatric COVID-19 vaccine in a variety of ways, and many parents may not fit neatly into the three reactions we list below. It’s possible to cite different types of vaccine hesitancy differently; for example, families hesitant to accept the vaccine could actually be facing obstacles in accessing the vaccine, as stipulated in this Washington Post opinion piece. The AAP has addressed the spectrum of vaccine hesitancy before in terms like “fence-sitter” and “go along to get along”. So in many cases, hesitancy is a gray area where pediatricians have the opportunity to ask about why caregivers have reservations.
Nonetheless, it’s important for pediatricians to understand the motivations and fears of parents, because for most caregivers, the emotional reaction to the news of a vaccine for kids comes from a desire to protect their children. Physicians can identify the general kinds of parents hesitant to get the vaccine to better reassure, empathize, and exchange the vital information that can lead to vaccination protection for kids.
Low Urgency or “Casual” Vaccinators
Some parents experience no hesitant emotions at all, and want their children to be vaccinated as quickly as possible. This is an attitude many physicians can celebrate, as it means that the children of these families can receive their shot promptly, and since their parents are not hesitant and sometimes even eager for the vaccination, they may be more likely to appear for both doses. However, a lack of hesitancy can appear different for each family, and their assent to a vaccine could be more casual than enthusiastic, leading some families to hover on the fence between doses.
Since it’s important to ensure that patients receive both doses of an approved COVID-19 vaccine and that their vaccine card is updated appropriately, careful vaccine tracking is important for all patients. Some PCC practices report doing the following to keep track of patients’ vaccines, even if they receive a second dose or booster elsewhere.
- Scan a copy of the vaccine card into the EMR
- Schedule a child’s second appointment at the first appointment
- Give the card into the caregiver’s keeping
- Offer spare COVID-19 cards offered by the state
- Verifying for the chart that patients received both doses at subsequent visits
With careful vaccine tracking, pediatric practices can urge families to return to complete the second dose of the COVID-19 vaccine and remind them in other ways, like Broadcast Messaging, not to miss it. Missed appointments or wariness over a second dose could be signals that the child’s physician should ask some supportive questions about fears or concerns about the vaccine in order to encourage families to complete the vaccine series.
Pediatric practices can prepare for this first wave of families lining up to get the vaccine with more logistical work. Patient recall can ensure timely appointments, reduce the stress of high patient volumes, and even prevent late or no show appointments. Check out our previous blog posts to learn how patient recall strategies and managing high visit volumes can help your practice.
About a third of parents are inclined to wait and see -- that is, observe how other children and families react to the vaccine. Liz Hamel of the Kaiser Family Foundation (KFP) noted that this could be a repeat phenomenon from the adult COVID-19 vaccine, where teens and young patients over 12 years old increasingly got the vaccine as their friends and neighbors did.
After the initial rush for vaccines for children, this is where the real work of vaccination communication will begin. Pediatricians can keep an ear out for phrases like “I’m not sure,” “We want to wait,” or “I’d prefer my older children to get the vaccine first” to identify families that could fit into this “wait and see” group. Practices can reassure families that reservations about health decisions in the interest of protecting their child are normal, and try to share digestible amounts of information on the vaccine and some personal experiences, such as why you chose to vaccinate your own child.
Practice managers can put plans in place to ensure that these “wait and see” families are met halfway -- set a reminder in your EHR to check back in with the family in a month or six weeks and revisit the conversation -- you may just find their position has changed.
Refuser caregivers might respond with “definitely not” or a similar firm refusal to give their child a COVID-19 vaccine, even if they’ve received the adult vaccine themselves. Current estimates from the KPP note that 30 to 31% of parents are refusing vaccines for their children at the time of this post’s writing. Liz Hemmel of the KPP notes that some families may need a lot more time and patience to come around to the idea of getting the shot for their kids.
The most powerful actions pediatricians can do are those that lean on the years of trust and solid relationships built with patients and families over time. When physicians speak to the parents of a child they’ve seen since birth, caregivers can be convinced that the vaccine is safe and effective, that there are limited long term effects, and that their child’s immune system will thank them for the extra immunity!
Practices might set reminders to revisit the vaccine conversation with parents, but they may also wish to compassionately bring the subject around during routine visits. Depending on your state’s Immunization information system (IIS), you may or may not be able to record that a parent refused the vaccine and why. You can set reminders in your EHR to prompt future visit discussions if your IIS does not allow this notation.
Discussions about vaccine hesitancy will be unique to your community and perspective, but the American Academy of Pediatrics (AAP) has resources for pediatricians to address hesitancy: by using participatory language, such as “You’re due for your second dose, so we’ll be giving the COVID-19 vaccine today”; or using the CASE response, an acronym for Corroborate, About Me, Science, and Explain/Advise.
Pediatric immunologist Dr. Paul Offit also offered advice as far back as the 2020 AAP National Conference & Exhibition to help pediatricians dealing with anxiety about a conflict of values between themselves and vaccine-refuser parents. First, he says that hesitancy is altogether reasonable given the rapidity of change during the pandemic, and secondly, he presented an idea from astrophysicist Neil deGrasse Tyson: essentially, if a physician and parent are coming to different conclusions using two totally different sets of values, reversing the parent’s beliefs may be a misguided effort.
Vaccine hesitancy can be alarming for physicians concerned about the health of their patient population, but there’s reason to celebrate too -- the first and best defense against vaccine hesitancy are the carefully built relationships that are unique to pediatrics.
Want a pediatrician’s take on vaccine hesitancy? Be sure to check out Dr. Suzanne Berman of Plateau Pediatrics in The Independent Pediatrician, for her perspective on the Department of Health anti-vaccine regulations that affect her state of Tennessee.