Lead author Saad B. Omer, MBBS, PhD, MPH, is assistant professor of global health and epidemiology at Emory University's Rollins School of Public Health, with coauthors from the Johns Hopkins Bloomberg School of Public Health, the federal National Vaccine Program Office and the Washington State Department of Health.

Perceptions and concerns about vaccine safety have led to a jump in vaccine refusal in the United States over the last decade. Several states allow "personal belief" exemptions from school vaccination requirements in addition to exemption for religious or medical reasons.

In the article, Omer and his colleagues review evidence from several states that vaccine refusal puts children in communities where the practice has increased at substantially higher risk for infectious diseases such as measles and pertussis.

Even children whose parents did not refuse vaccination are put at risk because "herd immunity" normally protects children who are too young to be vaccinated, can't be vaccinated for medical reasons, or whose immune systems do not respond sufficiently to vaccination, the authors explain.

"The implication of recent research findings is that everyone who is living in a community with a high proportion of unvaccinated individuals has an elevated risk," Omer says.

In a recent survey of pediatricians, almost 40 percent said they would not provide care to a family that refused all vaccines, and 28 percent said they would not provide care to a family that refused some vaccines.

The authors advise primary care physicians and nurses not to break off relationships with parents that decline vaccines, citing the "critical role clinicians can play in explaining the benefits of immunization and addressing parental perceptions and concerns about its risks."

The attitudes of physicians and nurses overlap with and have an influence on the families they serve, the authors say.

Research shows primary care providers for unvaccinated children were less likely to have confidence in vaccine safety and vaccines' benefits. In focus groups, parents who were uncertain about vaccinating their children were still open to discussions with clinicians.

The authors note an emerging trend for parents to delay rather than omit vaccination for their children, a phenomenon whose consequences could include exacerbation of health inequities.

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