Zachi Grossman, MD, Diego van Esso, MD. Stefano del Torso, MD, Adamos Hadjipanayis, MD, Anna Drabik, MSc, Andreas Gerber, MD, PhD,and Dan Miron, MD

Abstract: An electronic survey assessing primary care paediatricians estimations and practices regarding parents’ vaccination refusal was sent to395 members of the European Academy of Paediatrics Research in Ambulatory Setting network, with a response rate of 87%. Of respondents who vaccinate in the clinic, 93% estimated the total vaccine refusal rate as 1%. Of all respondents, 69% prefer a shared decision-making approach to handle refusing parents.

Key Words: vaccine, refusal, Europe, paediatricians, EAPRESnet

Accepted for publication August 19, 2010.

From the *Maccabi Health Services, Tel Aviv, Israel; †Primary Care Center“Pare Claret,

” Barcelona, Spain; ‡ULSS 16,

Padova, Italy; §Paediatric Department,

Larnaca General Hospital, Larnaca, Cyprus;

Institut fu¨r Gesundheitso¨konomie und klinische Epidemiologie IGKE, Koeln, Germany;

Institut fu¨r Qualita¨t und Wirtschaftlichkeit im Gesundheitswesen IQWiG,

Koeln, Germany; **

Pediatric Infectious Diseases Consultation Service, HaEmek Medical Center, Afula, Israel; and ††Ruth and Bruce Rappaport School of Medicine, Haifa, Israel.

Address for correspondence: Zachi Grossman, MD, 3 Hausner St, Tel Aviv

69372, Israel. E-mail:

Supplemental digital content is available for this article. Direct URL

citations appear in the printed text and are provided in the HTML and

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Copyright © 2010 by Lippincott Williams & Wilkins

DOI: 10.1097/INF.0b013e3181faaaa3

Vaccines are among the most effective tools available for preventing serious infectious diseases and their complications and sequelae.1 However, at the same time, public and parental concern about real or perceived adverse events associated with vaccines has increased causing reduced childhood vaccination rates in the United States.2

Parents rarely refuse vaccines in general, but more commonly follow novel vaccination schedules proposed by individual physicians rather than recommended by the authorities.1 In the United States, studies showed that some clinicians would prefer discontinuing their provider relationship with families that refuse vaccines.3 On the other hand, the American Academy of Paediatrics argues against discontinuing care for families that decline vaccines, recommending that paediatricians “share honestly what is known and is not known about the risks and benefits of the vaccine in question.”4

Vaccine refusal and use of alternative vaccination schedules have been described in several countries in Europe.5,6 The aims of our study were to assess European primary care paediatricians’ estimates, attitudes, and practices regarding parents’ vaccination refusal.


Paediatricians were recruited by the European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet). This network of 395 primary care paediatricians from 24 countries was established by EAP in 2008.7 An electronic survey was developed by EAPRASnet Steering Committee, and after validation
by national coordinators was then mailed to all members of the EAPRASnet. The survey had 3 sections: Demographics of respondents (including setting of vaccination), vaccine refusal (total/alternative schedules) in general and for specific vaccines, and management of refusal. Statistical analysis was performed with SPSS version 17. For all variables, frequencies were computed. Since paediatricians who vaccinate in the office might have a more accurate estimation of the problem than paediatricians who only discuss it with parents but cannot follow the results of their
discussion, a further analysis was done looking at the difference in the estimation of refusal between those 2 groups of paediatricians.

A subgroup analysis was conducted to answer the question whether there are differences between the refusals of specific vaccines. The subgroup analysis took into account only countries with number of respondents greater than 5% of the total. Crosstabs with related _2 tests were computed, and if a _2 test was not applicable because of violated assumptions, Fisher exact test was used instead.


Overall 342 (87%) of the surveys were appropriately filled.

Majority of respondents (78%) vaccinate in their office, 21% do not vaccinate, but discuss the issue with parents, and less than 1% neither vaccinate nor discuss. Overall 93% of respondents who vaccinate in the clinic estimated the vaccine refusal as _1% versus 84% of those who do not (_2 test, P _ 0.013). Of all respondents, 47% estimated the magnitude of partial refusal or of parents using alternative vaccination schedules as _1%, and 38% as 1% to 5%. Measles Mumps Rubella and Hepatitis B vaccines were the most frequently refused vaccines. The main reasons given by parents to the respondents for vaccination refusal are presented in Table 1.

The most frequently refused vaccines in the subgroup analysis countries (France, Germany, Israel, Italy, Spain, and Switzerland) as reported only from those paediatricians who vaccinate in their clinics are shown (vaccine specific data are provided in Table, Supplemental Digital Content 1,

Regarding all vaccines, except of inactivated polio vaccine, there are significant differences between the countries. As compared with all other 5 countries, the refusal rate for Hepatitis B was significantly higher in France.

In all, 64% of respondents did not think that parents who refuse some vaccines should switch to another paediatrician, while 9% endorsed this option. However, in cases of total refusal, 27% thought that parents should switch to another paediatrician. Only 12% of respondents thought that any form of vaccination refusal is always causing a disturbance to the physician-family relationship.

Finally, 69% of responding paediatricians preferred a shared decision-making approach to handle refusing parents, whereas 17% thought an authoritarian approach is more appropriate.


Our study shows that the magnitude of total parental refusal to all vaccines, as estimated by primary care paediatricians in Europe is negligible. To our knowledge, this is the first multinational evidence generated in Europe regarding vaccination refusal.

Physicians who actually vaccinate in their practices gave an even lower figure for total refusal rate than paediatricians who only discuss vaccination issues with parents. In a recent survey, vaccinations are administered at the paediatrician’s office in 8 of 31 European countries, in the healthcare centre in 9, and in multiple locations in 12 countries.8 This heterogeneity in vaccination settings across Europe can explain the different estimations. Our figures are similar to the most recent 2008 US National ImmunizationSurvey assessment of 0.6% of children 19 to 35 months of age receiving no vaccinations.9

TABLE 1. Parental Concerns Regarding Vaccines as

Perceived by Paediatricians

Reason Number %

Fear of adverse events in general 203 59.88

Fear that so many vaccines overload the immune 197 58.11

system of the baby

Believe in alternative or complementary medicine 161 47.49

It is better to suffer the disease than prevent 106 31.27

it with vaccines

Fear of vaccines causing autism 98 28.91

Believe that there is no risk to get ill from 93 27.43

vaccine preventable diseases

Vaccines cause brain damage 66 19.47

Vaccines contain mercury (thimerosal) 55 16.22

Fear of vaccines causing multiple sclerosis 53 15.63

Religious 11 3.24

Others 7 2.07

In our study, the frequency of partial refusal or alternative vaccination schedules was estimated by 38% of paediatricians as 1% to 5%. Partial refusal and alternative vaccination schedules result in under-vaccination, with the possible consequence of exposure of the under-vaccinated children to disease breakouts.

In the subgroup analysis, we have shown significant differences between refusal rates for specific vaccines in different countries. There seems to be a correlation between the high refusal rates for Hepatitis B in France possibly related to the 1997 report of central nervous system demyelination associated with that vaccine,10 and the very low coverage rate for that vaccine in France (30% in 2007) compared with all other European countries (90%–97% in 2007).11 However, it is difficult to explain differences between countries regarding other vaccines refusal rates found in our study.

According to the survey respondents, similar to the United States,1 the top reason for vaccine refusal or alternative schedules is parental fear of adverse events. Our study also highlights the belief in alternative medicine as a factor related to vaccine refusal.

In a survey of parents of school aged children in 4 US states in 2003, parents of exempt children were more likely than parents of vaccinated children to have providers who offered complementary or alternative health care.5

The majority of our responding paediatricians prefer a shared decision-making approach when facing refusing parents. Only 9% endorsed the option of discontinuing care. However, 27% would favour this approach toward parents who refuse all vaccines. These results are different from a similar survey done in 2005 among a national sample of US paediatricians in which 28% and 39% would dismiss a family for refusing selected vaccines and all vaccines, respectively.3 The relatively lower number of European paediatricians who are in favor of dismissing family refusing vaccines is in accordance with the American Academy of Paediatrics policy statement published in 2005, suggesting to address refusal by authors thank 342 EAPRASnet members for their cooperation in this project.

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