Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases

N Engl J Med. 2009 May 7;360(19):1981-8. doi: 10.1056/NEJMsa0806477.


Vaccines are among the most effective prevention tools available to clinicians. However, the success of an immunization program depends on high rates of acceptance and coverage. There is evidence of an increase in vaccine refusal in the United States and of geographic clustering of refusals that results in outbreaks. Children with exemptions from school immunization requirements (a measure of vaccine refusal) are at increased risk for measles and pertussis and can infect others who are too young to be vaccinated, cannot be vaccinated for medical reasons, or were vaccinated but did not have a sufficient immunologic response. Clinicians can play a crucial role in parental decision making. Health care providers are cited as the most frequent source of immunization information by parents, including parents of unvaccinated children. Although some clinicians have discontinued or have considered discontinuing their provider relationship with patients who refuse vaccines, the American Academy of Pediatrics Committee on Bioethics advises against this and recommends that clinicians address vaccine refusal by respectfully listening to parental concerns and discussing the risks of nonvaccination.

Publication types

  • Historical Article

MeSH terms

  • Child
  • Health Knowledge, Attitudes, Practice*
  • Health Personnel
  • History, 19th Century
  • History, 20th Century
  • History, 21st Century
  • Humans
  • Immunization Programs / legislation & jurisprudence
  • Mandatory Programs / history
  • Mandatory Programs / legislation & jurisprudence*
  • Professional Role
  • Risk
  • Treatment Refusal / psychology
  • Treatment Refusal / statistics & numerical data*
  • United States
  • Vaccination / history
  • Vaccination / legislation & jurisprudence*
  • Vaccines / adverse effects


  • Vaccines