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Literature Review

Addressing Parental Vaccination
Questions in the School Setting:
An Integrative Literature Review

Karlen E. Luthy, DNP, FNP-c
1
, Jana Burningham, MS, FNP-s

1
,

Lacey M. Eden, MS, FNP-c
1
, Janelle L. B. Macintosh, PhD, RN

1
,

and Renea L. Beckstrand, PhD, RN, CCRN, CNE
1

Abstract

School nurses work in a unique environment with key opportunities to address parental concerns and questions regarding
their child’s health. A common concern for parents during school enrollment is childhood vaccination safety and efficacy. As
public health leaders, school nurses are well respected among parents, therefore school nurses are in a prime position to
educate parents and promote childhood vaccinations while also dispelling common vaccination myths. The purpose of this
integrative literature review is to synthesize evidence-based answers to common parental questions regarding childhood
vaccinations.

Keywords

communicable diseases, community, health education, immunizations, integrative reviews

Vaccination mandates for schoolchildren were first

introduced in the United States during the early 1800s,

primarily to control the transmission of the smallpox virus

(College of Physicians of Philadelphia, 2015). Since that

time, several vaccines have been developed, protecting

children from a variety of potentially devastating commu-

nicable diseases (Centers for Disease Control and Preven-

tion [CDC], 2014a). Today, all 50 states have instituted

childhood vaccination requirements prior to school entry,

and while the requirements between states are similar,

there are also notable differences (CDC, 2011b).

Prior to receiving approval by the U.S. Food and Drug

Administration (USFDA) for widespread distribution, com-

mercially available vaccines undergo rigorous study, thus

ensuring vaccine safety and effectiveness (CDC, 2014a).

Following the collection of vaccination research, scientific

data, and results of clinical trials, the Advisory Committee

on Immunization Practices (ACIP) critically reviews the

information and then makes a recommendation on the age

of vaccine administration, the number of doses in a series,

the length of time between doses, and vaccine precautions

and contraindications (ACIP, 2013). The recommendation

is then forwarded to the Director of the CDC, where it must

receive final approval before becoming an official CDC

recommendation.

While the widespread use of vaccines has unquestion-

ably and positively influenced public health and safety, this

tremendous success has, in some cases, resulted in the

public’s lack of appreciation for the severity of vaccine-

preventable diseases (Kempe et al., 2011). Consequently,

some children are unvaccinated. The percentage of unvacci-

nated children in the United States, in fact, has more than

doubled since 1991 (Offit, 2011)—a worrisome trend that

could potentiate the spread of communicable and vaccine-

preventable diseases.

In school settings, children are able to attend class even if

inadequately vaccinated, as long as parents have filed a vac-

cination exemption (Wang, Clymer, Davis-Hayes, & But-

tenheim, 2014). There are three types of vaccination

exemptions in the United States: medical, religious, and phi-

losophical (Seither et al., 2014). All 50 states allow school

vaccination exemptions for medical reasons and, currently,

48 states allow school vaccination exemptions for religious

reasons (National Conference of State Legislatures [NCSL],

2015). Currently, 20 states allow parents to exempt their

children from school vaccination mandates on the grounds

of philosophical beliefs, such as personal or moral beliefs;

1
Brigham Young University, Provo, UT, USA

Corresponding Author:

Karlen E. Luthy, DNP, FNP-c, Brigham Young University, 457 SWKT,

Provo, UT 84602, USA.

Email: beth_luthy@byu.edu

The Journal of School Nursing
2016, Vol. 32(1) 47-57
ª The Author(s) 2015
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1059840515606501
jsn.sagepub.com

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http://jsn.sagepub.com

however, California and Vermont recently passed legislation

revoking the philosophical vaccination exemption, a change

that will take place in July 2016 (NCSL, 2015).

Parents who exempt their children from receiving vacci-

nations often have questions regarding vaccines. According

to one study, the most common parental concerns included

questions about vaccination safety, such as whether or not

childhood vaccines overwhelmed the immune system or

caused chronic illnesses. Parents also had questions regard-

ing vaccine effectiveness. In addition, parents often have

questions about how frequently children experience adverse

side effects from the vaccine (Luthy, Beckstrand, Callister,

& Cahoon, 2012). Some parents refuse a single vaccination

because they prefer their child develop acquired active

immunity from exposure to a specific pathogen rather than

a vaccination (Offit, 2011). Other parents have questions

regarding specific ingredients of vaccines and whether or not

these ingredients pose health risks (Luthy, Beckstrand, &

Meyers, 2012).

As the health care expert in the school setting, school

nurses are ‘‘well-poised to create awareness and influence

action to increase the uptake of mandated and recommended

immunizations’’ (National Association of School Nurses

[NASN], 2015, para. 1). In addition, school nurses ‘‘ . . . play
an important role in enhancing vaccine uptake by providing

a strong vaccine recommendation; educating about vaccine-

preventable diseases, vaccine myths, vaccine safety, and

recommended vaccine schedules; and addressing vaccine

hesitancy’’ (NASN, 2015, para. 8). Because school nurses

frequently and directly interface with parents, their ability

to adequately address parental questions regarding child-

hood vaccinations is of utmost importance. The purpose of

this integrative literature review is to synthesize evidence-

based answers to common parental questions regarding

childhood vaccinations.

Research Questions

Research Question 1: Is it possible for vaccines to over-

whelm the immune system?

Research Question 2: Do vaccines increase a child’s risk

for developing a chronic illness?

Research Question 3: Do vaccines contain ingredients

that can be harmful to children?

Research Question 4: Does the chicken pox disease pro-

vide better protection than the vaccine?

Method

Nine electronic databases were searched to identify articles

examining common parental questions regarding childhood

vaccinations and the evidenced-based answers to these

questions. All searches were guided by the research ques-

tions. The databases included CINAHL, MEDLINE,

Pubmed, Academic Search Premier, PsycINFO, Scopus,

Family & Society Studies Worldwide, Health Source: Nur-

sing/Academic Edition, and ERIC. Eight websites were

also reviewed, including the CDC, American Academy of

Pediatrics (AAP), ACIP, College of Physicians of Philadel-

phia, NCSL, Johns Hopkins Bloomberg School of Public

Health, Institute of Medicine, and NASN.

Inclusion criteria encompassed research or review arti-

cles published in English and within the past 15 years

(2000–2015). Additionally, only articles pertaining to chil-

dren and adolescents aged 0–18 years were included for

review. Research articles published outside the United States

and articles pertaining to adult vaccinations were excluded.

Search terms included immunize; immunization; vaccine;

vaccination; school nurse; parental questions; parental con-

cern; parental hesitant or refusal; parental attitudes; parent

perception; treatment refusal or refusal to participate;

measles, mumps, and rubella (MMR); autism; varicella;

herpes zoster; vaccine safety; vaccine effectiveness; vaccine

ingredients; and thimerosal.

Findings

Common parental concerns regarding childhood vaccines

were identified in a literature search. Two topics—safety

and efficacy—were the commonly shared concerns among

parents. Questions about vaccination safety included

concerns that vaccinations may overwhelm the immune

system, cause chronic illness, and contain worrisome ingre-

dients (Allred, Shaw, Santibanez, Rickert, & Santoli, 2005;

Hulsey & Bland, 2015; Humiston, Lerner, Hepworth,

Blyth, & Goepp, 2005; Kennedy, Lavail, Nowak, Basket,

& Landry, 2011; Luthy, Beckstrand, & Meyers 2012;

Smith, Chu, & Barker, 2004; Smith et al., 2011). In addi-

tion, parents often express concerns regarding vaccine

effectiveness and whether or not contracting the disease

provides a superior immune response when compared to

the immune response from vaccinations (Healy & Picker-

ing, 2011; Kempe et al., 2011; Luthy, Beckstrand, Calli-

ster, et al., 2012; Whyte, Whyte, Cormier, & Eccles, 2011).

Vaccine Safety

Research Question 1: Is it possible for vaccines to overwhelm the
immune system?. The idea that vaccinations have the poten-
tial to overload a child’s immune system is rooted in a few

inaccurate beliefs. One such belief is that the present num-

ber of vaccinations administered in the first 2 years of life

is excessive when compared to the number of childhood

vaccines delivered during the following decades (Kennedy,

Lavail, et al., 2011). Thus, some parents worry the number

of vaccines currently recommended introduces too many

antigens within too short a time period. These parents also

express concern that introducing too many antigens in the

first 2 years of life has the potential to overwhelm or over-

load the child’s immune system (Hulsey & Bland, 2015).

Additionally, some parents incorrectly believe that an

48 The Journal of School Nursing 32(1)

infant’s immune system is immature and, therefore, ill

equipped to respond to vaccines, at least until later in child-

hood (Luthy, Beckstrand, & Callister, 2010).

Response. It is true that the total number of vaccinations a
child receives by age 2 has increased over the last three

decades (Every Child by Two [ECBT], 2013b). However, the

total number of vaccines received during childhood is less

important than the number of antigens or immunological

components present within the vaccine. Every vaccine con-

tains antigens that include altered or weakened parts of

viruses or bacteria (National Institute of Allergy and Infec-

tious Diseases [NIAID], 2012). When exposed to the antigens

in vaccines, the immune system creates antibodies in order to

combat the viruses or bacteria, which are perceived as a

potential threat. Thankfully, the antigens in vaccines are pow-

erful enough to produce protective antibodies without actually

subjecting the child to the illness (CDC, 2014c). The vaccine-

induced antibodies remain in the body, continuously search-

ing for exposure to the same illness and then mounting a quick

immune response to negate the infection (NIAID, 2011).

From the moment of birth, an infant’s immune system is

challenged with millions of bacteria and other microorgan-

isms already present in the environment (Plotkin, Orenstein,

& Offit, 2013). Fortunately, an infant’s immune system is

capable of managing such challenges, otherwise infants

would become ill shortly after birth. In fact, within hours

of birth, an infant’s immune system has already successfully

managed the colonization of the gastrointestinal tract with

bacteria such as Escherichia coli (Gerber & Offit, 2009).

While vaccines also challenge an infant’s immune system,

vaccines cannot overutilize or overwhelm the immune sys-

tem (Immunization Action Coalition [IAC], 2014). In fact,

given the number of circulating B cells and T cells in an

infant’s immune system and the average number of antigens

present in a vaccine, researchers theorize an infant’s immune

system is capable of receiving 10,000 vaccines simultane-

ously (Gerber & Offit, 2009).

In the 1980s, only seven childhood vaccines were avail-

able. Today children receive up to 24 vaccines by the time

they are 2 years old (Children’s Hospital of Philadelphia

[CHOP], 2013c). While the overall number of vaccines has

increased over time, the amount of antigens present in vac-

cinations has decreased dramatically due to advances in the

vaccine manufacturing process, namely, in protein chemis-

try and recombinant DNA technology (CHOP, 2013c;

ECBT, 2013b; Gerber & Offit, 2009; Offit et al., 2002). For

example, in 1980, the typical child received 3,041 different

antigens in vaccinations. Currently, however, children are

exposed to only 152 antigens in all childhood vaccines com-

bined (ECBT, 2013b). When compared to the fact that chil-

dren are routinely exposed to 2,000–6,000 antigens with

everyday activities such as playing, eating, and breathing

(AAP, 2013), the number of antigens present in childhood

vaccines is inconsequential.

Research Question 2: Do vaccines increase a child’s risk for
developing a chronic illness?. Widely publicized myths exist
regarding a correlation between childhood vaccines and pre-

disposition to chronic illnesses although perhaps the most

well-known myth is that vaccines cause autism (Kennedy,

Basket, & Sheedy, 2011; Luthy, Beckstrand, Callister,

et al., 2012). The erroneous correlation between vaccines

and autism started in 1998 with Andrew Wakefield’s publi-

cation in the Lancet, which implied the MMR vaccine

caused autism. In Wakefield’s study, fiber optic scopes were

inserted into the large intestines of eight children with aut-

ism, all of whom had parents who believed their child’s aut-

ism was caused by the MMR vaccine. All of the children,

according to Wakefield, had lymphatic nodules in the large

intestine and suffered from chronic enterocolitis (Eggertson,

2010; Offit, 2010). Because all eight children had also

received the MMR vaccine, Wakefield hypothesized that

following MMR vaccination, the large intestines were

directly infected with the measles virus, thus causing chronic

inflammation (Offit, 2011). As a consequence, the chronic

intestinal inflammation compromised the integrity of the

intestinal wall, allowing the leakage of harmful proteins

from the intestines into the bloodstream. Once in the blood-

stream, the harmful proteins traveled to the brain where it

caused autism (Offit, 2010).

Following the publication of Wakefield’s study, a media

frenzy ensued and parents from around the world rapidly

became familiar with the concept—albeit an incorrect con-

cept—that a vaccine was to blame for the unexplainable

increase in autism rates (Dube et al., 2013). The public’s

concern was further fueled with public statements from

political leaders such as Congressman Robert F. Kennedy

Jr., and Senators John Kerry, Chris Dodd, and Joseph Lie-

berman, all of whom said they believed autism was caused

by vaccines (Olpinski, 2012). Additionally, celebrities such

as Jenny McCarthy used popular television shows such as

Oprah Winfrey Show, Good Morning America, and Larry

King Live to reach millions of people with antivaccine senti-

ment. While in the spotlight, McCarthy relentlessly insisted

that the MMR vaccine was the cause of her son’s autism

(Offitt, 2011).

The damage of the negative media coverage quickly

became evident. Parents began to delay and, in some cases,

completely refuse to vaccinate their children with MMR

(Poland & Spier, 2010). In a number of countries, MMR

vaccination rates fell and the incidence of measles began

to increase (Ahearn, 2010). Moreover, parents refusing to

vaccinate with MMR seemed to geographically cluster

together, resulting in pockets of unvaccinated individuals

throughout the world. Such geographic clusters have perpe-

tuated outbreaks of vaccine-preventable diseases, such as

measles (Smith et al., 2011). While the MMR vaccination

rates have slowly recovered around the globe, the World

Health Organization (WHO) recommends MMR vaccina-

tion rates of 95% in order to sustain a healthy herd immunity

Luthy et al. 49

(Andre et al., 2008). However, 113 countries out of a total of

194 countries still report MMR vaccination rates below 95%
(WHO, 2015).

Response. Well-controlled epidemiologic studies provide
strong evidence that vaccines do not cause chronic illnesses

such as multiple sclerosis, asthma, allergic rhinitis, diabetes,

or arthritis (Offit & Hackett, 2003). The most well-known

myth regarding vaccines and chronic illness, that vaccines

cause autism (Kennedy, Pruitt, Smith, & Garrell, 2011), has

been thoroughly studied in the years that followed Wake-

field’s publication. The Institute of Medicine (2004) con-

ducted eight safety review panels regarding vaccines and

autism and could find no association. Multiple studies con-

ducted by multiple researchers have since found no evidence

of a possible link between any vaccine and autism (Taylor,

Swerdfeger, & Eslick, 2014).

Brian Deer, an investigative journalist for the Sunday

Times, revealed that Wakefield’s study was not only flawed,

it was also unethical. Unbeknown to his research colleagues,

Wakefield received US$800,000 from a personal-injury

lawyer who was planning on suing the vaccine manufactur-

ers shortly after the release of Wakefield’s article (ECBT,

2013a; Offit, 2010). In 2004, 10 of the original 12 coauthors

retracted their names from the article, stating that the data

were insufficient to establish a causal link between the

MMR vaccine and autism (Murch et al., 2004). In February

2010, 12 years after its original publication, the Lancet

retracted the entire article (Eggertson, 2010). Due to his

fraudulent research linking the MMR vaccine and autism,

Andrew Wakefield was asked to leave his place of employ-

ment at the Royal Free Hospital and lost his license to prac-

tice medicine in the United Kingdom (Park, 2010).

Several professional organizations dedicated to finding a

cure for autism have published position statements regarding

autism and vaccines. One such example is Autism Speaks

(2015a), the world’s leading autism science and advocacy

organization. Rob Ring, the Autism Speaks Chief Science

Officer stated, ‘‘over the last two decades, extensive

research has asked whether there is any link between child-

hood vaccinations and autism. The results of this research

are clear: Vaccines do not cause autism. We urge that all

children be fully vaccinated’’ (Autism Speaks, 2015b, para. 1).

Additionally, the Autism Science Foundation (ASF), a

nonprofit organization, whose mission is to support autism

research and provide autism education to the general public

(ASF, 2015b) stated, ‘‘The results of studies are very clear;

the data show no relationship between vaccines and autism’’

(ASF, 2015a, para. 1).

Research Question 3: Do vaccines contain ingredients that can be
harmful to children?. Although vaccines are primarily com-
posed of antigens—the substances responsible for stimulat-

ing a healthy immune response—vaccines also include small

amounts of other ingredients also known as adjuvants.

Adjuvants are compounds added to vaccines with the pri-

mary purposes of either enhancing the immune response

or preserving the vaccine’s safety (CDC, 2014b; Gellin &

Salisbury, 2015). However, oftentimes the purpose for adju-

vants in vaccines is not well explained (Gellin & Salisbury,

2015). Thus, parents may not understand the need for vac-

cine adjuvants and express concern regarding the safety of

such adjuvants (Saada, Lieu, Morain, Zikmund-Fisher, &

Wittenberg, 2015). Some adjuvants are especially worri-

some to parents (Saada et al., 2015), especially those that

intuitively sound harmful to children such as aluminum, for-

maldehyde, or mercury.

The release of Dr. Robert Sears’ (2007) best-selling pub-

lication, The Vaccine Book: Making the Right Decision for

Your Child, further stimulated the debate regarding the

safety of adjuvants in vaccines, thus promoting vaccine

anxiety among parents. For example, while Sears admits

‘‘research has not proven that the aluminum in vaccines is

harmful,’’ he also states ‘‘some research shows that when too

much aluminum is given at once, some toxic effects can

occur’’ causing neurologic and degenerative conditions

(p. 22). Formaldehyde, Sears says, is the same chemical that

‘‘preserved the frogs, cats, or whatever types of cadavers you

dissected in biology class’’ (p. 209). He goes on to say that

formaldehyde is present in several vaccines and in the very

next sentence states that formaldehyde is ‘‘a carcinogen’’

that ‘‘can cause kidney damage and genetic damage’’

(p. 209). Finally, Sears also weighed in on mercury use in

vaccines. In his book, Sears states, ‘‘Do I think mercury is

harmful? Yes. Do I think the amount in the old vaccines

caused harm? I think no one has proven that it was safe, and

the studies showing some harmful effects from vaccines

containing mercury are thought-provoking’’ (p. 209). While

on one hand, Sears admits that mercury toxicity from vac-

cines is ‘‘a thing of the past’’ (p. 209), he simultaneously

recommends parents ask their ‘‘doctor for a completely

mercury-free brand’’ (p. 208) of flu vaccine to limit the

amount of mercury children receive in vaccines.

Response. It is true that aluminum is used as an adjuvant in
vaccines. The purpose of aluminum in vaccines is to stimu-

late an early, potent, and persistent immune response (CDC,

2011a). While some parents may be alarmed at the inclusion

of aluminum in vaccines, the amount of aluminum needs to

be contextualized. Aluminum is an element that is abundant

in nature. It is, in fact, the third most plentiful element on the

planet, right behind oxygen and silicon, and is present in

plants, water, soil, and air (CHOP, 2014). The amount of

aluminum in vaccines is comparable to the amount of alumi-

num in 1 L of infant formula. During their first 6 months of

life, infants receive approximately 4.4 mg of aluminum from

vaccines. However, during the same time span, infants who

are breast-fed ingest about 7 mg of aluminum from breast

milk. Furthermore, formula-fed infants ingest about 38 mg

of aluminum and infants who are fed soy-based formula

50 The Journal of School Nursing 32(1)

ingest about 117 mg of aluminum (CHOP, 2014). It is

important for parents to know that the amount of aluminum

in vaccines is small compared to what infants already

receive in their normal diet (Block, 2013). Nevertheless,

aluminum has been safely used as an adjuvant in vaccines

for almost six decades (USFDA, 2015).

Formaldehyde is used in some vaccines to inactivate

viruses and remove naturally occurring bacterial toxins from

vaccines without influencing the overall vaccine efficacy

(Mitkus, Hess, & Schwartz, 2013). There is only a small

amount of formaldehyde used in vaccines, although the

small amount is further diluted during the vaccine manufac-

turing process (USFDA, 2014). While the use of such a sub-

stance in vaccines may seem unsettling for some parents,

formaldehyde is already present in the human body, where

it is utilized in the process of making amino acids (USFDA,

2014). The amount of formaldehyde that children are

exposed to during vaccination can be as high as 0.2 mg;

however, the amount of formaldehyde already naturally

present in an average 2-month-old infant is about 1.1 mg.

Thus, the amount of formaldehyde already self-produced

in an infant’s body is 5 times greater than the amount present

in a vaccine (CHOP, 2013d). Furthermore, formaldehyde is

metabolized so quickly that it cannot accumulate in the

human body (American Chemistry Council, 2015). In fact,

Mitkus, Hess, and Schwartz (2013) reported that 30 min fol-

lowing injection of a formaldehyde-containing vaccine,

there were no residual traces of formaldehyde at the injec-

tion site. Hence, formaldehyde is safely used as a component

in some vaccines.

Thimerosal is an ethyl-mercury compound used as an

adjuvant in some vaccines to prevent bacterial growth,

although it is quickly processed in the body (CDC,

2011a). Some parents, however, confuse ethyl-mercury

with methylmercury. Methylmercury is present in fish and

shellfish and, because it is slowly excreted from the body,

has the potential to cause neurotoxicity when ingested in

large amounts (Offit & Moser, 2011; U.S. Environmental

Protection Agency, 2014). While ethyl-mercury may audi-

bly sound similar to methylmercury, the two compounds

are chemically very different. Notwithstanding these dif-

ferences, in 2001, ethyl-mercury was removed from virtu-

ally all vaccines, with the exception of some influenza

vaccines (CDC, 2014b), in response to a joint statement

from the AAP and the U.S. Public Health Service (AAP,

1999). However, the statement was based upon data regard-

ing methylmercury exposure and neurotoxicity, not expo-

sure to ethyl-mercury. No causative link has ever been

established between ethyl-mercury and neurological disor-

ders in children (Hurley, Tadrous, & Miller, 2010).

Vaccine Effectiveness

Research Question 4: Does the chicken pox disease provide better
protection than the vaccine?. Traditionally, chicken pox has

been viewed not as a dangerous infectious disease but rather

a common disease virtually all children had before adult-

hood (CHOP, 2013a). In fact, before the chicken pox (vari-

cella) vaccine in 1995, parents often viewed chicken pox

simply as a rite of passage during childhood (Offit & Moser,

2011). Some parents would even have their child attend

chicken pox ‘‘parties’’ (Hambleton & Arvin, 2005) to ensure

infection with the chicken pox virus during childhood when

the infection was typically milder (IAC, 2015; Offit &

Moser, 2011).

With the availability of a new chicken pox vaccine, states

began to pass legislation, requiring chicken pox vaccination

prior to school entry (Lopez, Kolasa, & Seward, 2008). Such

legislation markedly improved the uptake of chicken pox

vaccine and, as a result, cases of chicken pox in the United

States decreased 10-fold (CHOP, 2013a). While the chicken

pox vaccine was successful in reducing the cases of chicken

pox, still, about 15–20 children in every 100 did not develop

sufficient immunity to chicken pox after one dose of the vac-

cine (CHOP, 2013a). As a result, some parents began to

doubt the effectiveness of vaccines when compared to the

long-lasting immunity from contracting the illness (Luthy,

Beckstrand, & Meyers 2012).

In 2007, a study published in the New England Journal of

Medicine reported that children who initially developed

chicken pox immunity after the first vaccination did not have

long-lasting immunity, meaning the efficacy of the chicken

pox vaccine waned with time (Chaves et al., 2007). Chaves

et al. further reported that children who had received their

chicken pox vaccine within 5 years had a reduced risk for

developing a moderate or severe case of chicken pox. In con-

trast, children who received the chicken pox vaccine more

than 5 years ago had an increased risk for developing moder-

ate or severe chicken pox (Chaves et al., 2007). In response,

the ACIP updated the childhood vaccine schedule in 2007,

recommending a second dose of chicken pox vaccine (Marin,

Guris, Chaves, Schmid, & Seward, 2007). Despite the change

in vaccination schedule, some parents still questioned

whether or not ‘‘natural immunity’’ following chicken pox

infection was superior to the immunity developed after two

chicken pox vaccines (Offit & Moser, 2009).

Response. Exposure to the natural illness produces a superior
immune response when compared to the immune response

following vaccination (CHOP, 2013b). However, parents

should carefully consider the risk of exposing a child to a

disease process as opposed to the risk of receiving a vaccina-

tion. While diseases often produce lifelong immunity, the

infections are often accompanied by moderate to severe dis-

ease symptoms and, in some cases, can result in long-lasting

effects or even death (CHOP, 2013b). Vaccines, on the other

hand, provide immunity without the potential consequences

of the disease (Offit & Moser, 2011).

One clear example of the benefits of vaccination in lieu of

disease is chicken pox, caused by the varicella-zoster virus.

Luthy et al. 51

With chicken pox disease, the varicella-zoster virus can

migrate from the skin lesions to the nervous system, where

it can remain dormant for many years (Offit, 2011). Later

in adulthood, though, the varicella-zoster virus can ree-

merge, causing a shingles infection. Similar to chicken pox

infection, shingles causes an outbreak of painful rash with

blisters on the skin that can last up to 5 weeks (National

Institute of Neurological Disorders and Stroke [NINDS],

2015). Unfortunately, 20–30% of shingles patients over 60
years old develop post-herpetic neuralgia, a secondary com-

plication of shingles (Fashner & Bell, 2011). Furthermore,

individuals suffering from shingles can also transmit the

varicella-zoster virus to unvaccinated children (NINDS,

2015), thus perpetuating chicken pox infection.

While chicken pox infection carries a lifelong risk of a sec-

ondary shingles infection, the chicken pox vaccine protects

against chicken pox while simultaneously lessening the risk

for shingles infection as an adult (Offit & Moser, 2011). In

fact, those who receive two doses of chicken pox vaccine are

50% less likely to develop shingles later in life. Furthermore,
the chicken pox vaccine also reduces the incidence of post-

herpetic neuralgia by 66%. Even in patients who develop
shingles despite receiving the chicken pox vaccination, a sub-

sequent shingles infection is much less severe (National Foun-

dation for Infectious Diseases, 2009). Therefore, while

naturally acquired immunity is perhaps longer lasting,

vaccine-induced immunity spares the individual from experi-

encing the disease and lessens the risk and intensity of sec-

ondary illnesses such as shingles and post-herpetic neuralgia.

Discussion

Providing accurate vaccine education to parents is an impor-

tant strategy to reduce vaccine hesitancy (Kestenbaum &

Feemster, 2015), albeit the school nurse must first establish

an ideal environment, wherein the parent–nurse conversa-

tion can occur. At the very foundation of effective commu-

nication with vaccine-hesitant parents is the principle of

respect. Facilitating a respectful interaction between school

nurse and parents with vaccine concerns promotes trust and

may ultimately help guide parents toward the decision to

vaccinate (Leask et al., 2012). In addition to establishing

respect, Healy and Pickering (2011) recommend establish-

ing an open and honest dialogue, where parents can express

their vaccine concerns without feeling as though they are

being judged. With this type of environment, parents who

are uninformed but educable usually respond favorably to

vaccination education (Healy & Pickering, 2011).

While it may be tempting to utilize fear tactics during

communication, for example, trying to alarm parents with

the dreaded consequences of contracting a vaccine-

preventable illness, such communication strategies may be

ineffective with some parents (Nyhan, Reifler, Richey, &

Freed, 2014). Although anti-vaccine activists often capita-

lize on anecdotal storytelling to instill fear and doubt in

parents with questions regarding vaccines (Shelby & Ernst,

2013), pro-vaccine messages that instead focus on myths

and facts with evidence to counteract the myths appear to

be an effective strategy in increasing parents’ existing

knowledge regarding vaccines (Cameron et al., 2013). In

addition, it is helpful to not only understand parents’ vacci-

nation beliefs but also determine the process by which par-

ents came to their conclusions (Brunson, 2013), such as

under the influence of a friend or trusted family member.

With this knowledge, the school nurse can tailor the vaccine

education to meet parents’ needs.

Because parents may still have lingering questions regard-

ing vaccinations, even after receiving in-depth information by

the school nurse, it is helpful to suggest additional resources,

where parents can access accurate and reputable information

(Healy & Pickering, 2011). It is important for the school nurse

to guide the parents to specific and reputable websites rather

than simply encouraging the parents to search the Internet for

answers, where they are required to filter through less than

reputable websites with inaccurate information. Parents who

have no guidance in their search for further information will,

in fact, encounter more sites with incorrect information than

with correct information, which could perpetuate vaccination

myths (Ruiz & Bell, 2014).

Implications for School Nurses

The public identifies nurses as experts in health-related mat-

ters (Miller & Reynolds, 2009) and as trusted sources of

health-related information. In fact, according to a recent

Gallup poll, the American public perceived nurses to be both

honest and ethical in their interactions (Riffkin, 2015). Addi-

tionally, nurses have topped the list of the most ethical pro-

fessionals for well over a decade (American Nurses

Association, 2015). As trusted health authorities, nurses

have an ethical responsibility to promote the health and

well-being of the patients entrusted to their care. Encoura-

ging parents to vaccinate their children and offering in-

depth information regarding the safety and efficacy of

vaccinations promotes the health and well-being of school-

aged children and is one of the many ethical responsibilities

of school nurses.

School nurses are on the front lines of educating the public

on vaccinations and ‘‘should use evidence-based immuniza-

tion strategies, such as . . . strong vaccination recommenda-
tions, and vaccine education for students, staff, and

families’’ (NASN, 2015, para. 1). Consequently, it may be

helpful for school nurses to have ready-made resources to

direct vaccine-concerned parents to reputable resources (see

Table 1). Furthermore, school nurses should have access to

trustworthy materials, which can be easily accessed and uti-

lized to share concise and consistent vaccination information

with parents, perhaps through regular e-mail correspondence,

on the school’s Facebook page, or through school newsletters

(see Table 2).

52 The Journal of School Nursing 32(1)

Table 1. Resources to Guide Parents With Vaccine Concerns.

Author(s) Title Resource Type Availability
Cost

(Approximately)

P. A. Offit and L. M.
Bell

Vaccines: What You Should Know

Book Online and traditional bookstores.
Paperback and kindle

US$30

P. A. Offit and C. A.
Moser

Vaccines and Your Child: Separating
Fact From Fiction

Book Online and traditional bookstores.
Paperback and kindle

US$15

P. A. Offit Deadly Choices: How the Anti-Vaccine
Movement Threatens Us All

Book Online and traditional bookstores.
Hardcover, paperback

US$15

P. A. Offit Autisms False Prophets: Bad Science,
Risky Medicine, and the Search for a
Cure

Book Online and traditional bookstores.
Paperback and kindle
US$15

M. G. Myers and D.
Pineda

Do Vaccines Cause That?! A Guide for
Evaluating Vaccine Safety Concerns

Book Online and traditional bookstores.
Paperback, audiobook, and kindle

US$12

American Academy
of Pediatrics

Immunization Resources: Addressing
Common Concerns of Vaccine-
Hesitant Parents

Website http://www2.aap.org/immunization/
pediatricians/pdf/vaccine-hesitant%
20parent_final

Free

American Academy
of Pediatrics

Immunizations Website https://www.healthychildren.org/english/
safetyprevention/immunizations/pages/
default.

aspx

Free

Children’s Hospital
of Philadelphia

Parents PACK Website with
videos and
newsletters

http://vec.chop.edu/service/parents-
possessing-accessing-communicating-
knowledge-about-vaccines/home.

html

Free

Luthy, Asay, Gibson,
and BYU College
of Nursing

Reasons to Immunize YouTube video https://www.youtube.com/watch?v¼
6J92tWPYA_U

Free

L. M. Eden Measles, Mumps, & Rubella (MMR)
Vaccine

Website https://youtu.be/kxEqRnxMft8 Free

American Academy
of Pediatrics

Questions and Answers About Vaccine
Ingredients

Website http://www.vaccinateyourbaby.org/pdfs/
Vaccine_ingredients

Free

Every Child by Two Parents’ Guide to Immunizations Website with
electronic
booklet

http://www.ecbt.org/images/articles/
Complete2014GuideGeneric

Free

Table 2. School Nurse Materials for Distribution of Vaccine-Related Information.

Author(s) Title Resource Type Availability Cost

Immunization Action
Coalition

Responding to Parents Website with handouts http://www.immunize.org/talking-
about-vaccines/responding-to-
parents.asp

Free

Centers for Disease
Control and
Prevention

Provider Resources for Vaccine
Conversations With Parents

Website with handouts http://www.cdc.gov/vaccines/hcp/
patient-ed/conversations/

Free

Association of State and
Territorial Health
Officials

Communicating Effectively About
Vaccines: New Communication
Resources for Health Officials

Website with free print adds http://www.astho.org/WorkArea/
DownloadAsset.aspx?id¼5464

Free

Children’s Hospital of
Philadelphia

Vaccine Update for Healthcare
Providers

Website with free newsletters
and webinars

http://vec.chop.edu/professionals/
vaccine-healthcare-providers/
home.html

Free

American Academy of
Pediatrics

Immunization FAQs Website with free question
and answer handouts

http://www2.aap.org/immunization/
families/faq.html

Free

Vaccine News Daily Latest Headlines Website with daily vaccination
headlines

http://vaccinenewsdaily.com/ Free

Immunizations for Public
Health

Are Vaccines Safe? Evaluating
Information on the Internet

Pdf pamphlet for download http://immunizationinfo.com/wp-
content/uploads/2015/03/Are_
Vaccines_Safe

Free

Luthy et al. 53

http://www2.aap.org/immunization/pediatricians/pdf/vaccine-hesitant%20parent_final

https://www.healthychildren.org/english/safetyprevention/immunizations/pages/default.aspx

http://vec.chop.edu/service/parents-possessing-accessing-communicating-knowledge-about-vaccines/home.html

https://www.youtube.com/watch?v=6J92tWPYA_U

https://youtu.be/kxEqRnxMft8

http://www.vaccinateyourbaby.org/pdfs/Vaccine_ingredients

http://www.ecbt.org/images/articles/Complete2014GuideGeneric

http://www.immunize.org/talking-about-vaccines/responding-to-parents.asp

http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/

http://www.astho.org/WorkArea/DownloadAsset.aspx?id=5464

http://vec.chop.edu/professionals/vaccine-healthcare-providers/home.html

http://www2.aap.org/immunization/families/faq.html

http://vaccinenewsdaily.com/

http://immunizationinfo.com/wp-content/uploads/2015/03/Are_Vaccines_Safe

Conclusion

Vaccination rates are steadily declining in part due to paren-

tal concerns regarding safety and efficacy. Although vacci-

nations are required prior to school enrollment, exemption

rates continue to increase. School nurses are on the front

lines, interacting with vaccine-hesitant parents, and must

provide factual and evidenced-based information to parents

about vaccinations. Therefore, it is imperative school nurses

have access to resources that provide accurate and pertinent

information regarding common parental concerns for child-

hood vaccinations. School nurses are in a position to help

decrease vaccinations exemption rates through parent edu-

cation while using reliable resources.

Authors’ Contribution

Karlen E. Luthy contributed to conception, design, acquisition,

analysis, and interpretation; drafted and critically revised article

for important intellectual content; and gave final approval. Jana

Burningham contributed to conception, design, acquisition, analy-

sis, and interpretation; drafted and critically revised article for

important intellectual content; and gave final approval. Lacey M.

Eden

contributed to conception, design, acquisition, analysis, and

interpretation; drafted and critically revised article for important

intellectual content; and gave final approval. Janelle L. B. Macin-

tosh contributed to conception, design, acquisition, analysis, and

interpretation; drafted and critically revised article for important

intellectual content; and gave final approval. Renea L. Beckstrand

contributed to conception, design, acquisition, analysis, and
interpretation; drafted and critically revised article for important

intellectual content; and gave final approval.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, author

ship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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main.A826

Author Biographies

Karlen E. Luthy, DNP, FNP-c, is a Associate Professor at Brig-

ham

Young University.

Jana Burningham, MS, FNP-s, is a Graduate Student at Brigham

Young University.

Lacey M. Eden, MS, FNP-c, is a Assistant Teaching Professor at

Brigham Young University.

Janelle L. B. Macintosh, PhD, RN, is a Assistant Professor at

Brigham Young University.

Renea L. Beckstrand, PhD, RN, CCRN, CNE, is a Professor at

Brigham Young University.

Luthy et al. 57

http://www.fda.gov/BiologicsBloodVaccines/ScienceResearch/ucm284520.htm

http://apps.who.int/gho/data/node.main.A826

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Copyright of Journal of School Nursing is the property of Sage Publications Inc. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

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