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Paediatrics clinic

To sign or not to sign. Dealing with requests for vaccination exemption

Frank H Beard, Nicholas Wood
OPEN ACCESS

Determining which of these five groups a parent falls into can assist healthcare providers to tailor their advice and management. In general providing guidance that focuses on benefits and risks of vaccination compared with disease, supported by access to written and online resources and offering further discussion, is recommended.

Refusers are often particularly challenging for GPs to deal with. Potential strategies include keeping the discussion brief but leaving the door open, acknowledging rather than dismissing their concerns, avoiding overt confrontation, and offering another appointment when they are ready or attendance at a specialist immunisation clinic.3  There are a range of resources available to assist healthcare providers and parents.3-5  Good communication with a parent who is worried about vaccinating their child requires patience, empathy, good listening skills and being responsive to specific concerns in an honest, frank and open manner.

In some cases, parents may wish to be selective about which vaccines the child receives. This can have the advantage of building confidence for the parent; if the schedule is started with no adverse events then acceptance of continuing or completing the schedule may increase. The disadvantage is that administering one vaccine at a time requires extra visits, does not significantly reduce the adverse event profile and requires a longer time to complete the recommended vaccine schedule, potentially putting the child at greater risk of acquiring infection. Splitting up vaccines into separate components – for example, giving the Haemophilus influenzae  type b (Hib) component only of a multivalent vaccine – is not recommended. Parents should be advised that there is no additional safety benefit to splitting up vaccines and that for some vaccines, such as the measles mumps rubella vaccine, monovalent component vaccines are not available.

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The risk of natural infection for individual children differs according to their age and this can be explained to parents. Although for many vaccine preventable diseases the disease risk is low, for others such as pertussis the disease is less well controlled and is particularly an issue for infants who are at highest risk of the more severe consequences of the disease including death. In the case of tetanus, the causative pathogen (Clostridium tetani ) is ubiquitous in the environment and is contracted by injury or wounds rather than person to person. So tetanus is therefore a potential risk to all children once mobile and is only able to be prevented by vaccination.

It is important to explain to parents that the risk of contracting a vaccine preventable disease also increases with travel, although this does depend on the destination of travel. In many countries the risk of infection is substantially higher than in Australia, and access to post-exposure treatment, such as tetanus immunoglobulin, can also be problematic.

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Conclusion

There are few valid reasons to sign an Immunisation Medical Exemption form under the tightened requirements introduced in conjunction with the no jab, no pay policy in Australia. Specialist immunisation services are available in some states to assist healthcare providers in determining whether a valid medical exemption exists for individual children and advise on the management of adverse events following immunisation. Sustaining high vaccination coverage is required to control vaccine preventable diseases in Australia. MT

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Dr Beard is a Staff Specialist Public Health Physician at the National Centre for Immunisation Research & Surveillance of Vaccine Preventable diseases (NCIRS), Sydney; and Senior Lecturer in the School of Public Health at the University of Sydney. Dr Wood
SERIES EDITOR: Dr Chris Elliot BMed(Hons), FRACP, is General and Developmental Paediatrician, St George Hospital, Sydney; and Conjoint Lecturer, School of Women's and Children's Health, UNSW Sydney, NSW.