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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:
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DOI: 10.1177/1059840515606501
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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
http://www2.aap.org/immunization/pediatricians/pdf/vaccine-hesitant%20parent_final
http://www2.aap.org/immunization/pediatricians/pdf/vaccine-hesitant%20parent_final
https://www.healthychildren.org/english/safetyprevention/immunizations/pages/default.aspx
https://www.healthychildren.org/english/safetyprevention/immunizations/pages/default.aspx
https://www.healthychildren.org/english/safetyprevention/immunizations/pages/default.aspx
http://vec.chop.edu/service/parents-possessing-accessing-communicating-knowledge-about-vaccines/home.html
http://vec.chop.edu/service/parents-possessing-accessing-communicating-knowledge-about-vaccines/home.html
http://vec.chop.edu/service/parents-possessing-accessing-communicating-knowledge-about-vaccines/home.html
https://www.youtube.com/watch?v=6J92tWPYA_U
https://www.youtube.com/watch?v=6J92tWPYA_U
https://youtu.be/kxEqRnxMft8
http://www.vaccinateyourbaby.org/pdfs/Vaccine_ingredients
http://www.vaccinateyourbaby.org/pdfs/Vaccine_ingredients
http://www.ecbt.org/images/articles/Complete2014GuideGeneric
http://www.ecbt.org/images/articles/Complete2014GuideGeneric
http://www.immunize.org/talking-about-vaccines/responding-to-parents.asp
http://www.immunize.org/talking-about-vaccines/responding-to-parents.asp
http://www.immunize.org/talking-about-vaccines/responding-to-parents.asp
http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/
http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/
http://www.astho.org/WorkArea/DownloadAsset.aspx?id=5464
http://www.astho.org/WorkArea/DownloadAsset.aspx?id=5464
http://www.astho.org/WorkArea/DownloadAsset.aspx?id=5464
http://vec.chop.edu/professionals/vaccine-healthcare-providers/home.html
http://vec.chop.edu/professionals/vaccine-healthcare-providers/home.html
http://vec.chop.edu/professionals/vaccine-healthcare-providers/home.html
http://www2.aap.org/immunization/families/faq.html
http://www2.aap.org/immunization/families/faq.html
http://vaccinenewsdaily.com/
http://immunizationinfo.com/wp-content/uploads/2015/03/Are_Vaccines_Safe
http://immunizationinfo.com/wp-content/uploads/2015/03/Are_Vaccines_Safe
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://www.fda.gov/BiologicsBloodVaccines/ScienceResearch/ucm284520.htm
http://apps.who.int/gho/data/node.main.A826
http://apps.who.int/gho/data/node.main.A826
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