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Running Head: VACCINE PERCEPTIONS

What are Parents’ Attitudes Towards Vaccinating Their Children?

Hannah Gallagher, Daelyn Lazor, Graham Mincher, Josh Pickett and Tommy Warg

10 April 2019

NURS 3947: Nursing Research

Dr. Valerie O’Dell

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Abstract

Throughout recent history, vaccinations have been a large solution to many medical issues that

previously were unpreventable. What has been deemed one of the most significant public health

achievements in history, now has an untrusting, questioned effect by many parents. This paper

discusses the different reasons on why vaccinations are viewed negatively by parents primarily

for four separate reasons: the study conducted by Andrew Wakefield, a controversial chemical

that is believed to still be found in vaccines, religious reasoning, and lack of education or

misinformation. By looking at each of these four topics, one can see how attitudes towards

vaccines have gone downhill, while the solution to the issue is simply using evidence-based

studies to educate the public. Despite the negativity, the majority of parents still do vaccinate

their children, and view it as an extremely important health precaution.

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What are Parents’ Attitudes Towards Vaccinating Their Children?

Decades ago, there was a time where vaccinating children was not a question that would

warrant much thought. Vaccinating children was a common practice done by the vast majority of

parents knowing it would bring protection to their children from harmful and deadly diseases.

However, the publication of a poorly conducted study by a British researcher and medical doctor

led to the decline of this high rate of vaccination. Although the study was discredited rather

quickly, it left a lasting impact on society. Today, this impact shows itself in the form of an

“Anti-Vaccination” movement, which are parents choosing not to vaccinate their children, and

others who show support for parents and legislators who are against vaccination. This movement

is leading to a decrease in vaccinations in children, and in correlation, an increase of these

diseases that were once controlled. Although countless studies and research articles have been

published proving these vaccinations to be safe, the stigma still lingers from a faulty correlation

made with no real facts to back it. However, this one study did not set the framework for every

case of non-vaccination. Other cases where parents may have been uneducated or misinformed,

along with religious practices can also attest to the dropping percentage of vaccinations. Due to

this drop of vaccinations in the past few decades, the following research question was addressed:

What are parents’ attitudes towards vaccinating their children?

Literature Review

Introduction

In order to conduct accurate research on the public perceptions of vaccinations, journal

entries and articles were gathered via OhioLINK databases as well as Google Scholar. A total of

ten sources were reviewed for comprehensive data collection regarding the topics of vaccines

and the perceptions that people have on them. Such topics as the linkage to autism, is there a
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linkage to thimerosal to autism, other possible reasons why people may choose not to vaccinate

and the prevalence of preventable diseases.

Vaccines Linkage to Autism

The development of vaccines is one of the most important advances in the history of

medicine. Vaccines prevent and protect many people from harmful and deadly diseases.

However, over the past two or three decades, numbers are rising for parents in the industrialized

world who are choosing not to have their children vaccinated. This caused many diseases that

have been completely wiped out or become much rarer to come back into circulation causing the

number of people diagnosed to increase. In trying to explain why these parents are refusing to

vaccinate their children, scientists and public health commentators refer to the activities of the

anti-vaccination movement. A social movement whose false theories are well-known to many

individuals. One specific contributor to this movement is Andrew Wakefield and his article The

Lancet, which discusses possible links between the measles, mumps, and rubella (MMR)

vaccination and autism. Although this article is no longer available, lingering doubt is still a

popular belief amongst many people. According to an informational survey taken by D. Lazor

(Do you believe vaccines cause autism, April 3, 2019), three out 33 people believe that there is

some sort of link between autism and vaccinations. This shows that doubt still exists possibly

due to lack of education and the availability of sources lacking credibility.

In February 1998, Dr. Andrew Wakefield, a British researcher, and twelve of his

colleagues published a case series in The Lancet, a peer reviewed medical journal, linking autism

with the MMR vaccine. The Lancet, suggested that the MMR vaccine may predispose children to

behavioral regression and developmental disorders. This caused MMR vaccination rates to drop,

despite Wakefield’s small test sample, uncontrolled design, and the uncertain conclusion.
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McLeod (2014) states “Despite the fact that Wakefield’s study was considerably flawed with a

subject pool of just 12 children in Britain, only eight of which were diagnosed with autism, a

subsequent drop in vaccination rates among children in the United States and Britain ensued” (p.

1). Even though Wakefield’s data was flawed the damage had been done causing many to avoid

vaccinating children for the fear of causing autism. Almost immediately after the entry was

published epidemiological studies were conducted and published refuting Wakefield’s claim.

Another entry in The Lancet, written by ten of the twelve co-authors of Wakefield, was a

short retraction of Wakefield’s work. The entry stated, there was no causal link between MMR

vaccine and autism as the data was insufficient. In February 2010, The Lancet completely

removed Wakefield’s paper after finding several of his claims in his entry to be false. Years after

the entry was removed, evidence emerged that Wakefield had falsified his data linking the

vaccine with developmental disorders and subsequently lost his license to practice medicine in

England. However, despite scientists proving Wakefield’s claims to be false, the damage was

done and many feared possible side effects of vaccinations which caused parents to stop

vaccinating their children. Due to Wakefield, and later the anti-vaccination movement, lingering

doubts persist and in many regions of the world, MMR vaccination rates lie below the

recommended 95% uptake.

Despite the growing scientific evidence that proves vaccines are safe and are not a link to

autism, the anti-vaccination movement, a stubborn minority, continues to claim otherwise. This

is a threat to the health and common good of society. Public support for the vaccination program

in the United States still remains high where rates are around 95%. According to McLeod

(2014), “The National Vaccine Injury Compensation Program record evidence of the people who

are seriously injured by vaccinations every year. However, there have only been 3,645
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substantiated claims in the 25 years of the program’s existence – about 146 people a year, most

of which are anaphylaxis or encephalitis upon administration of the vaccine, not long-term

developmental disorders” (p. 2). For the large amount of people who live in the United States

that is a very low statistic, especially since the study was over 25 years. McLeod (2014) also

states, “Given that almost 2 billion vaccines were administered between 2006 and 2012, this

comes out to be about a 0.00005% chance of having a life-threatening reaction” (p. 2). However,

despite all the scientific evidence proving vaccinations are safe, people still refuse to vaccinate

their children, which results in diseases that have been long eradicated, now returning to the

country.

Thimerosal Link to Autism?

One of the biggest concerns with vaccines are the possible toxic elements and ingredients

contained in the vaccination itself. A controversial compound found in some vaccines is the a

mercury-containing preservative called thimerosal, which is found in the MMR and DTaP

(diphtheria, tetanus and pertussis) vaccine. This preservative is feared to have the possibility of

causing an increased risk of autism in a child when given the vaccine. There are specific types of

bacteria in the environment that can change the inorganic form of mercury and convert it into

organic mercury or methylmercury, which in extreme doses can be neurologically toxic to your

body. Another form of mercury, called ethylmercury, is a substance that is rapidly broken down

and excreted from the body and therefore does not accumulate or cause harm. According to the

Federal Drug Administration (FDA), through testing and research, the mercury (thimerosal) used

in vaccinations is metabolized into ethylmercury and thiosalicylate only (Biologics Evaluation

and Research, 2018). Therefore, the neurotoxic substance, methylmercury, is not contained in
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these vaccines, but rather only ethylmercury, which poses no threat to those who receive the

vaccinations.

Nonetheless, thimerosal is no longer found in a majority of childhood vaccines, but

parents still believe that it is contained in the vaccines and causes neurodevelopmental disorders

and autism. In a meta-analysis epidemiologic study containing 1,256,407 children in five cohort

studies looking at the possible correlation between the MMR vaccination and autism, as well as

thimerosal exposure and autism. The study concluded that there was no evidence for the

association between autism and the MMR vaccination, as well as no substantial evidence for

exposure to thimerosal causing autism or autism spectrum disorders (Taylor, Swerdfeger, Eslick,

2014). The FDA also noted that other studies over the past 15 years do not show any evidence of

thimerosal harm in vaccines, such as the risk for autism or neurodevelopmental disorders

(Biologics Evaluation and Research, 2018). Therefore, there is no substantial evidence for

parents to not vaccinate their children based on the idea that thimerosal, in vaccines, causes

autism and neurodevelopmental disorders.

Other Factors

Although there is a popular perception that autism may be caused by the use of

vaccinations, this is not the only reason why a parent may choose to not get their child

vaccinated. There are many other reasons as to why one may choose to leave their child

unprotected from preventable diseases. First, however, it must be understood that the choice to

give the recommended vaccinations to a child exists in a spectrum. A parent may feel uneducated

and unsure with their decisions or may only refuse certain ones, such as MMR and DTaP, which

are believed to contain certain harmful chemicals as stated above. A parent may also delay their

child’s vaccination schedule until they are older because they feel that a child’s immune system
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is not strong enough to handle all of the recommended doses in such a short period of time

(McNeil, Mueller, MacDonald, Mcdonald, Saini, Kellner and Tough, 2019). The decision to

vaccinate is influenced by many factors that cause a parent to lean towards one side of the

argument or the other.

The most common argument many have against the use of vaccinations is due to religious

beliefs. The idea that using such preventative measures goes against the foundation of one’s core

belief system and causes them to not vaccinate their child. According to McKee and Bohannon

(2016), federal law does not require parents to vaccinate their children in order to attend public

schools if they have a medical exemption. Forty-seven of those states also allow religious

exemptions, which is the most common reason one may not vaccinate. It should be noted that

these parents do not choose this option because they are ignorant or uneducated on the topic, but

rather a deep core belief that will probably never be subject to change in the near future.

The argument most commonly offered for why specific vaccinations oppose religious

tenets involves components of the vaccines. The animal-derived gelatin used in

producing some vaccines as well as the human fetal tissue used in the rubella component

pose the largest concern (McKee & Bohannon, 2016).

Research on ways to produce the vaccines in mediums that are acceptable by these religions need

to be at the forefront of research to convince this group to otherwise vaccinate their children.

Another common reason why a parent may chose to not vaccinate their child is due to

their personal belief or philosophy on the subject matter. Though most states do not allow

exemptions for this reason, it is becoming a more common reason due to the relevance of bias

vlogs, social media and certain celebrities who try to persuade parents that vaccinations are

indeed unhealthy. Some of the personal beliefs that parents hold include such reasons as: it may
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be beneficial for some children to contract these diseases, natural immunity may have a greater

benefit compared to immunity through vaccinations and even the fact that many of the diseases

we vaccinate against do not seem to be very prevalent so why medicate against them (McNeil et

al, 2019)? Brieher, Edwards, Mudgil and Whitehall conclude that the majority of parents who

denied the MMR vaccine felt that measles had a very low severity compared to parents who

chose to vaccinate. They believe that the vaccine is more dangerous than the disease itself, which

is not accurate. People may have the personal opinion that vaccines are more harmful than the

disease itself, but this ideology affects everyone around them as well by allowing the

reintroduction of preventable diseases back into the United States.

Preventable Disease

Parents who delay and or skip childhood vaccinations for their children, even when the

child has no medical reason to do so, are contributing to the increasing outbreak of some of the

diseases that could be prevented with the use of vaccinations. These diseases include but are not

limited to: measles, pertussis, poliomyelitis (polio), hepatitis, varicella and pneumococcal

diseases. Two of these diseases are making a comeback as a result of the refusal or failure to

vaccinate children are measles and pertussis.

According to The Center for Disease Prevention (CDC), measles is a virus which

is paramyxovirus, the genus Morbillivirus which causes a systemic infection in

the body and affects the respiratory endothelium of the nasopharynx. If left

untreated, it can cause ear infections resulting in permanent hearing loss as well as

pneumonia which is the leading common cause of death from measles in young

children. More severely, measles can lead to subacute sclerosing panencephalitis,

which is a rare but fatal disease of the central nervous system that results seven to
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ten years after a individual has fully recovered from measles earlier in their life

(Complications of Measles, 2018).

In the past 63 years, medical professionals have tried to eradicate measles three times: in 1962

when the measles vaccination first came out, once again in 1989-1992 , then again from 1997-

1999. By the start of the year 2000, measles was almost completely eradicated in the United

States. However, due to parents worry, incorrect knowledge of vaccinations in the last two

decades and failure to vaccinate their children, the rate of measles is beginning to increase once

again. Between January 1, 2001 and November 30, 2015 there were 1416 reported cases of

measles in individuals between the ages of two weeks and 84 years old. Of those 1416

individuals, 199 cases were individuals with a history of receiving the MMR vaccine, while 804

did not receive the MMR vaccination and 405 individuals who did not know if they received the

vaccination or not (Phadke, Bednarczyk, Salmon, Omer p. 6-7, 2016). One of the most recent

outbreaks of measles occurred in late 2014 starting at Disneyland in Anaheim, California,

resulting in 111 cases in seven U.S. states, Mexico and in Canada. Approximately half of the 111

cases were among individuals who were eligible for vaccinations, yet remained unvaccinated

intentionally (p. 3). Measles has had an increasingly high incidence throughout the past years,

yet when compared to pertussis it is still very small.

Pertussis also known as “whooping cough” is a highly contagious respiratory disease

caused by the bacteria Bordetella pertussis. It causes violent coughing attacks creating the

“whooping” sound making it hard to breathe. This is one of the most serious and deadly diseases

a child or baby may contract. The CDC states that, “1 out of every 4 babies will get pneumonia,

1 out of 100 (1.1%) will have convulsions (violent, uncontrolled shaking), 3 out of 5 (61%) will

have apnea (slowed or stopped breathing), one out of every three (0.3%) will have
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encephalopathy (disease of the brain), one out of every hundred (1%) will die.” As a result, it is a

deadly disease that needs to be prevented in order to protect children from being affected

(Complications of Pertussis, 2017).

Like measles, pertussis continues to remain a large problem in the United States. In the

ten years from 2006 until 2016, there were more than 10,000 cases of pertussis that were

reported annually, which was higher than what had been observed in over 50 years. A meta-

analysis study which included other studies within and outside of the U.S. noted that the

possibility of acquiring pertussis increased approximately 1.33 times for each consecutive year

since the last vaccination of DTaP. As a result, it is associated with a waning immunity to

pertussis, requiring multiple doses of pertussis containing vaccines in order to maintain a

protective immunity to this disease. It is recommend that children get vaccinated with the DTaP

at: two, four, six months, then again at fifteen and eighteen months, once again at four and six

years old and finally a booster between eleven and twelve (Phadke, et. Al, p. 11, 2016). Phadke

and his other co-authors noted that in nine epidemiological reports that:

Characterized the reasons that case patients were intentionally unvaccinated or under-

vaccinated- these reasons included personal belief (or philosophical) exemptions (70% of

unvaccinated cases in 2012), religious beliefs or exemptions (84% of unvaccinated cases

in Florida in 2013, 59-93% of unvaccinated cases in 4 separate outbreaks in

Massachusetts from 1986-1988), cultural norms (72% unvaccinated in an Amish

Community in Delaware in 2004-2005, 79% unvaccinated in an Amish Community in

Illinois in 2009-2010,) illness at the time a vaccine dose was due, inability to appear for

the vaccination appointment, or hesitance on the part of vaccine provider.

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In 2014, there was an outbreak of pertussis which resulted in 222 cases in neonates and infants

under 12 months of age, all of which had a detailed vaccination history. Of the 222, only 53 of

the participants received the DTaP vaccine, although over half of those infants were age-eligible

(p. 12). As a result of parents intentionally vaccinating or under-vaccinating their children, the

pertussis epidemic is becoming an increasingly growing problem in today’s society that may be

simply overlooked by parents.

Conclusion

Over the past few decades, parents’ attitudes towards vaccinations have changed due to

non-evidence-based reasons. A study published in The Lancet by British Doctor Andrew

Wakefield has had lasting implications on parents’ beliefs that vaccinations are directly linked to

autism. This poorly conducted study led to an increase in parents’ negative views regarding

vaccines and resulting in a drop in vaccination rates amongst children. Although numerous

studies and research articles have been published proving these vaccinations to be safe, the doubt

still lingers from this study made by Dr. Wakefield. Another reason why parents do not vaccinate

their children is based upon religious beliefs or personal philosophy rather than being poorly

educated, resulting in the reintroduction of many preventable diseases that were once thought to

be eradicated. Further education for parents will be essential in effort to advocate for the safety

of their children. Teaching by healthcare providers is the key for a safer and healthier future by

reducing the stigma against vaccinating one’s child.

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References

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vaccines.” US Food and Drug Administration Home Page, Center for Biologics

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www.fda.gov/biologicsbloodvaccines/safetyavailabilit

y/vaccinesafety/ucm096228#pres.

Brieger, D., Edwards, M., Mudgil, P., & Whitehall, J. (2017). Knowledge, attitudes and opinions

towards measles and the MMR vaccine across two NSW cohorts. Australian and

New Zealand Journal of Public Health, 41(6), 641-646. doi:10.1111/1753-6405.12720

Complications of Measles CDC. (2018, February 5). Retrieved March 23, 2019, from

https://www.cdc.gov/measles/about/complications.html
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Complications of Pertussis CDC. (2017, August 7). Retrieved March 22, 2019 from

https://www.cdc.gov/pertussis/about/complications.html

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Mcneil, D. A., Mueller, M., Macdonald, S., Mcdonald, S., Saini, V., Kellner, J. D., & Tough, S.

(2019). Maternal perceptions of childhood vaccination: Explanations of reasons

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