Challenging the 'acceptable option': Public health's advocacy for continued care in the case of pediatric vaccine refusal

Background: In the United States, nearly half of pediatricians dismiss or refuse to accept families that withhold consent from the administration of childhood vaccines. Since 2016, the American Academy of Pediatrics has called patient dismissal in these cases "an acceptable option." Clinician dismissal and non-acceptance pose a problem to public health because they cluster under-vaccinated children in the practices that remain willing to treat such children, and they decrease access to routine care for children who cannot find practices willing to accept or retain them. This paper reports the emergence of a new consciousness about dismissal and nonacceptance policies in the leadership of a local health department (LHD) of a populous metropolitan county. Objectives: To understand the prevalence and diversity of patient dismissal within Oakland County, Michigan and to measure shifts in clinicians' attitudes about dismissal following an educational intervention. Methods: A preliminary community survey was distributed to immunizing providers during April 2023 with 61 responses measuring the frequency and reasoning for dismissal policies. The results of the survey were used to inform a brief, evidence-backed educational intervention which was delivered in June 2023 to 82 participants from local pediatric medical offices. Results: The initial survey was completed by 61 immunizing providers, representing an estimated 37% of vaccinating practices in the county. Half said their practice "always" or "sometimes" dismisses patients due to vaccine refusal. After the educational intervention, the proportion of participants who agreed/strongly agreed with the statement "I believe patient dismissal for vaccine refusal is a good choice for public health" decreased from 36% to 18%. Conclusion: The changes that we observed between the pre- and post-intervention surveys demonstrate the opportunity that exists for LHD leaders to enter the conversation around patient dismissal and nonacceptance and shed new light on this issue.