The state of Texas has seen a rise in the number of patients opting out of recommended vaccinations. What have you seen as the effects of this rise in opting out? How have you seen Texas hospital teams handle patient interaction and patient education for those patients and families who do not follow medical recommendations for vaccinations?

Texas Hospital Association


As I have been in administration for many years, my experience is with hospital staffs. In Tenet Healthcare, I helped develop one of the early influenza immunization policies. Given that our inpatient population was, in many cases, elderly and possibly immunocompromised by illness or treatments, immunization for health care workers was a mandate. We carefully looked at requests for personal, allergic, or religious reasons and found few reasons to allow a refusal. Workers with an acceptable excuse to not be immunized were required to wear masks during flu season. Hand hygiene was emphasized. We saw no flu spread in our hospitals.

Influenza immunization was a priority of the CDC at that time with an increasing number of avoidable deaths due to lack of immunization in the population. As I recall, the CDC made the case that the hospitalized patient was an ideal group to immunize due to age and complex illness who required hospitalization. The CDC felt the opportune time to immunize this group was while they were in hospital. Influenza vaccination became a core measure of quality for U.S. hospitals. Florida was the first state that put this requirement into law and until that time, physicians deferred the immunization stating they would give the shot in the office. Our data showed that the follow-up immunization was a rare event. Thanks to the change in protocol, immunizations rates increased, and deaths decreased.

The same approach was used in the hospitalized patients and all unimmunized patients were offered the shot. Refusing immunization documentation with reason was a required part of the medical record.

The importance of sharing vaccination science with refusing patients is important. While logical discussions may not work, it is important to share the tragedies of avoidable illness and death common in the pre-immunization world and the recurrence of epidemics in unimmunized populations.

For my personal reasons for being a strong advocate of immunizations, listen to THA's latest Solutions podcast at

Texas Children's Hospital, Houston


Less than two decades ago, measles, a very contagious and potentially deadly disease, was declared eliminated in the United States. As a nation, we were able to accomplish eradication of this serious childhood illness through vaccination. Unfortunately, over the past two decades, parents have increasingly chosen to exempt their children from childhood vaccines based on misinformation. Today, with more than 56,000 children exempt from one or more childhood vaccines in the state of Texas, we find our state and nation facing the highest number of measles cases since eradication in 2000. As a result, some children and adults are now at risk of contracting measles. There is no doubt, the current measles cases represent a call to action for every medical professional – physicians, nurses, staff and hospital administrators.

In the spirit of “do no harm,” we must first ensure we cannot transmit diseases, such as measles, to our patients. Make it a priority to confirm that your workplace is in compliance with the Center for Disease Control and Prevention health careworker vaccination recommendations. Regarding measles, all employees should have presumptive evidence of immunity to measles which includes any of the following: written documentation of vaccination with two doses of live measles or MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957 (see for additional details).

Parents of patients may approach any member of our medical teams with questions regarding vaccines, especially now when a disease like measles is frequently in the news. For this reason, vaccine communication training for our team members is especially important. Here are important thoughts to consider:

First, recognize how important your advice is to those around you. If parents or patients know you work for a local medical practice or hospital, they will listen intently for your advice. Be clear when you talk about the importance of vaccines. Vaccines are safe, effective and they save lives. Period.

Second, always offer vaccines using presumptive words. Research has shown that parents, even vaccine-hesitant parents, are more likely to accept a vaccine when presumptive words are used. For instance, say, “Today, your daughter needs all of her 4-year-old vaccines – MMR, varicella, DTaP, and polio,” instead of, “Have you thought about giving your daughter her 4-year-old vaccines today? The latter option is likely to be met with more caution and resistance; parents may even question your own thoughts about the importance of vaccines.

Third, if a parent has questions about the vaccines, such as MMR, listen carefully to the source of those concerns. Have the parents read misinformation on the internet? Have wellmeaning friends given them bad advice? Do they have a child with developmental delay in the family? It is important to understand the source of the concern to address the concern correctly.

Finally, use the CASE method to talk with families. Developed by Alison Singer, CASE stands for Corroborate, About me, Science, Explain/advise. Following careful listening, medical professionals need to offer the vaccine-hesitant parent or patient a statement to establish common ground – a corroboratory statement. Strong corroboratory statements include thoughts such as: “Other parents have mentioned that concern to me,” or “That is a common story others have shared with me.” Following a corroboratory statement, providers and staff then explain their role in the medical profession as someone who has learned about the importance of vaccines (“About me”). Then, the provider explains the science that directly addresses the concern that was voiced by the parent or patient. To conclude, the provider or staff member should offer their best medical advice regarding the situation at hand (Explain/advise). Be clear and directive. Again, vaccines are safe, effective and save lives. Period.