Immunization is widely considered to be the greatest achievement of public health.Immunization is widely considered to be the greatest achievement of public health. In 1900, 30.4% of all deaths occurred among children under age 5; in 1997, that percentage was only 1.4% (Association of State and Territorial Health Officials, 2016). This is attributed to overall improved sanitation, immunizations, antibiotics, and access to medical care. The initial, immediate benefit of vaccination is to the individual, who is now protected from the disease he is immunized against. The second, delayed, benefit of vaccination is to the community. Herd immunity occurs when enough people are protected against a disease, which then cannot gain a foothold and circulate.

Different diseases require different vaccination thresholds to keep the disease away; once the threshold dips, outbreaks may occur. A recent analysis of vaccination benefits found that immunizing the 2009 United States (U.S.) birth cohort would result in 42,000 fewer deaths and 20,000,000 fewer cases of vaccine-preventable illnesses, with a net savings of $69 billion in total societal costs (Zhou, 2011).

Background

Trends in Hesitancy
Vaccination rates have been dropping in developed countries.Vaccination rates have been dropping in developed countries. Outbreaks of preventable infectious diseases are increasing, and the rise of anti-vaccination movements is thought to be a major contributing factor to these outbreak clusters. Vaccine hesitancy (VH) is defined by the World Health Organization as “the reluctance or refusal to vaccinate despite the availability of vaccines” (2019, Vaccine Hesitancy section, para. 1). It has been listed by the WHO as one of the top ten threats to global health (WHO, 2019).

Fears related to vaccine safety, vaccine side effects, and perceived associations between vaccines and neurodevelopmental disorders drive fears of vaccines and induce parents to reject vaccination for their children. Studies have demonstrated that in counties in the United States with higher rates of vaccine exemptions (either religious, medical, or personal belief), clusters of vaccine-preventable illnesses rise (Imdad et al., 2013). Other barriers to vaccination include lack of access to immunizations, inconvenience and time constraints, and perceived barriers by parents who believe that vaccines are not covered by insurance (Hendriksz, Malouf, Sarmiento, & Foy, 2013).

2019 Measles Outbreak
The recent measles outbreak of 2018-2019 in the United States occurred primarily in New York State. The disease was brought into the country by an unimmunized international traveler, and as of this publication, over 1,200 cases have been reported to the local and national health departments, with 119 hospitalizations (CDC, 2019).

The epicenters of this outbreak were the ultra-Orthodox Jewish communities...The epicenters of this outbreak were the ultra-Orthodox Jewish communities in Brooklyn, New York, and in Rockland County, a large religious enclave in northern New York State. Orthodox Jews make up approximately 500,000 people in an 8-county New York area (UJA Federation, 2015), and Rockland County has the largest Jewish population per capita of any U.S. county, with 31.4%, or 90,000 residents, being Jewish (Official Website of NY, n.d.). The median patient age was 5 years, and the measles vaccination coverage in schools in the outbreak area was only 77%, well below the threshold needed to maintain herd immunity (Mcdonald et al., 2019). An active anti-vaccine movement within the community, and widespread vaccine misinformation are thought to have been key contributors to decreased vaccination rates and the outbreak.

The purpose of this article is to describe the concern that vaccine hesitancy presents and provide evidence-based, recommended steps to combat this public health problem. The article also describes the grassroots effort led by a local group of nurses in their battle to address vaccine hesitancy and misinformation in their Orthodox Jewish community. Healthcare providers interested in providing vaccine education and correcting misinformation will find answers to common vaccine concerns, and receive communication tips, tools, and other recommended methods to address vaccine hesitancy.

Vaccine Hesitancy

Causes
Misinformation about vaccine safety is prevalent on the internet and on social media.Vaccines have been so successful at eradicating and reducing illness that many parents are now complacent and unfamiliar with the risk conferred by vaccine-preventable diseases (Calandrillo, 2003). Misinformation about vaccine safety is prevalent on the internet and on social media. Healthcare professionals and evidence-based information are replaced with volunteers without a medical background who devote their time to study an issue in depth, known as “citizen scientists” (Consortium for Science, Policy and Outcomes, 2019). However, lack of medical education reflects a poor understanding of immunology, pharmacology, research methodology, and pathophysiology, leading these volunteer researchers to erroneous conclusions. Personal anecdotes shared by parents who blame vaccines for developmental delays or illnesses are shared and viewed thousands of times. Concerns about vaccine safety, insufficient time to discuss these concerns during short clinic visits, and inadequate responses from pediatricians further contribute to rising vaccine hesitancy (McKee & Bohannon, 2016).

As many as 1 in 5 people believe that there is a link between vaccines and autism.Significance of the Problem
As many as 1 in 5 people believe that there is a link between vaccines and autism.As many as 1 in 5 people believe that there is a link between vaccines and autism (Public Policy Polling, 2013). In 2006, a study by the American Academy of Pediatrics (AAP) found that 75% of pediatricians had encountered vaccine hesitant parents, and by 2013 this figure had increased to 87% (AAP, 2006; Hough-Telford et al., 2016). The providers in these surveys reported that the percentage of parents who refused one or more vaccines increased from 9.1% to 16.7% during this time.

Vulnerable Communities
Over 75% of the recent outbreaks of vaccine-preventable illnesses have occurred in isolated, vulnerable communities (Reddy, 2019). Often, these communities have been targeted by anti-vaccine activists, who sense that communities with knowledge deficits, language barriers, or cultural barriers may be easily infiltrated by anti-vaccine sentiment. After concerted efforts by anti-vaccine activists to undermine faith in vaccines, measles vaccination in Somali communities in Minnesota dropped from 92% in 1994 to 42% in 2014 (Dyer, 2017). In 2010 and 2011, two talks were given in the Somali community by anti-vaccine advocate and former physician Andrew Wakefield (Dyer), and in 2017 the community experienced the biggest measles outbreak in 30 years (Branswell, 2017).

The Minnesota Department of Health learned that the community members wanted to receive information from trusted community sources.In these cases, traditional methods of reaching the community, by circulating educational videos or handouts, failed. The Minnesota Department of Health learned that the community members wanted to receive information from trusted community sources. Community approaches were initiated with great success. Somali healthcare workers were hired, and small conversations and talks were hosted throughout the communities. Imams began endorsing vaccinations, and suspicion of vaccines slowly decreased (Vaccine Confidence Project, 2016).

In 2014, a measles outbreak occurred in the Amish community in Ohio. It was noted at the time that the immunization rate for the measles, mumps, and rubella (MMR) vaccine in the community was only 88% (Gastañaduy et al., 2016). The World Health Organization recommends community vaccination levels of greater than 95% (Funk, 2017). This undervaccination led to the spread of the measles after two unimmunized individuals returned from the Philippines, causing 178 cases. Again, public health officials involved the local health department, who had established relationships with the community and included bishops and local community members in their efforts to curtail the outbreak (Gastañaduy et al., 2016).

The burden of speaking with vaccine hesitant parents falls primarily on pediatric health providers.The Role of Pediatric Health Providers
The burden of speaking with vaccine hesitant parents falls primarily on pediatric health providers. One study found that nearly 80% of parents confirmed that their decision to vaccinate was primarily influenced by their provider (Taylor et al., 1997). A more recent study found that a “well-informed pediatrician who effectively addresses parental concerns and strongly supports the benefits of vaccination has enormous influence on parental vaccine acceptance” (Smith, Kennedy, Wooten, Gust, & Pickering, 2006, p. e7). Common barriers to discussions about vaccine safety with concerned parents include time constraints as well as providers’ inadequate knowledge about vaccine science and safety. In one study which evaluated how providers (n = 696) communicate with vaccine hesitant parents, 53% of physicians reported spending 10-19 minutes in conversation (Kempe et al., 2011). However, in a telephone survey of 2,000 parents, 70% of parents reported that most child well-visits took under 20 minutes (Halfon, Stevens, Larson, & Olson, 2011). It becomes difficult for pediatric providers to do a comprehensive physical exam, discuss developmental milestones, give vaccines that are due, and have extensive conversations with parents regarding vaccine safety.

Outbreak Causes in New York Orthodox Jewish Community
These sources of anti-vaccine rhetoric went unchallenged for many years.A Jewish anti-vaccine activist group was identified as the source of myriad instances of misinformation that have slowly spread throughout the Orthodox Jewish community in the form of print magazines and telephone conferences (Pager, 2019). In order to maintain a religious and cultural lifestyle, the ultra-Orthodox Jewish community practices solitary, insular living and rejects modern influences, including secular media. Community magazines, circulars, and dial-in telephone conferences are a common source of “kosher” information for many members. Since 2014, anti-vaccination magazines and dial-in telephone conferences have emerged in the community, rife with misinformation, false experts, and emotional anecdotes (Schaffer, 2019a). These sources of anti-vaccine rhetoric went unchallenged for many years. Left without access to evidence-based information, it is not surprising that vaccination rates in these neighborhoods dropped and that these communities saw a rise in vaccine hesitancy. Large families, insular lifestyles, and low immunization rates primed this community for an outbreak.

There were several responses by Orthodox leadership to the growing measles outbreak...Orthodox Jewish Community Response
There were several responses by Orthodox leadership to the growing measles outbreak in the New York communities. Orthodox Jewish physicians, alarmed at the rising number of cases, implored their communities to follow the scientific evidence and help contain the outbreak. Five hundred community physicians signed a letter, distributed to the entire community, asking parents to vaccinate their children (Oster, 2019). Orthodox politicians, from the city to the state level, exhorted their constituents to vaccinate their families (The Yeshiva World, 2019). Hatzalah, a volunteer emergency medical service organization serving mostly Jewish communities, held MMR vaccine drives and placed ads in local circulars, endorsing vaccination (Maimonides Medical Center, 2019). Der Yid, a Yiddish-only language newspaper with a circulation of over 50,000 took the rare step of printing a full-page editorial in English, denouncing community members who do not vaccinate, citing religious mandates to vaccinate children (Der Yid, 2019).

The EMES Initiative

...a local group of Orthodox Jewish nurses felt the need to address the broad misinformation they were encountering in their own communities.Alongside these efforts, a local group of Orthodox Jewish nurses felt the need to address the broad misinformation they were encountering in their own communities (Hogan, 2019; Zaltzman, 2019). We formed the Engaging in Medical Education with Sensitivity (EMES) Initiative, a non-profit organization dedicated to bringing evidence-based health information to the Orthodox Jewish community in a culturally-sensitive manner. In Hebrew, “Emes” means truth/honesty. We determined that our first project would be vaccine education, and the Vaccine Task Force was formed.

Our nurses held extensive conversations with community members about concerns related to vaccine safety and their relationships with their pediatricians. We determined that lack of access to evidence-based information, and to providers with the time to review their concerns, were the primary reasons that these parents withheld immunizations for their children. In seeking to rectify these gaps, members of the initiative launched a flexible, multipronged approach: (1) providing evidence directly to parents about vaccine safety and vaccine-preventable diseases via several methods; (2) teaching parents how to discern information from misinformation, including how to read studies and evaluate data; (3) hosting workshops for providers to improve communication with patients, and to provide quick answers to common vaccine myths; and (4) acquiring buy-in from, and offering training to, para-health professionals, such as doulas, therapists, emergency medical technicians (EMTs), and others interested in learning how to combat anti-vaccine misinformation.

...we engaged in two-way feedback about what would be most helpful to this community.EMES chose a fluid approach, depending on the requests and needs of the Orthodox Jewish community in New York. This fluidity was necessary as we engaged in two-way feedback about what would be most helpful to this community. EMES incorporated direct parent and healthcare provider education, print materials, confidential and personal "one-on-one" communication, vaccine fairs, and living room workshops to address vaccine hesitancy in this community.

Parent Education
Several dozen nurses on our team researched and created content to use for educating the Orthodox community about vaccine safety and the importance of immunization. We understood that mistrust of the government, the pharmaceutical industry, and occasionally of the entire medical industry, leads vaccine hesitant parents to reject information from these entities. Therefore, we went to the original sources, using studies and data from scientists who are neither affiliated with pharmaceutical industries, nor with anti-vaccine movements.

All material was written at an 8th grade reading level, and citations were included for every statement.All material was written at an 8th grade reading level, and citations were included for every statement. Topics included: how the immune system works; how vaccines work; trends in vaccine-preventable illness; and the risks of not vaccinating. Common concerns about vaccines were addressed and rebutted using data and charts. Side-by-side comparisons were made of gross yearly earnings of the alternative health sector and those from vaccines in the pharmaceutical industry. Flu shot development, hepatitis B seroconversion, autism and its history of diagnostic changes, and many more topics were included in our materials.

Print Materials. This information was woven into an evidence-based magazine, called PIE (Parents Informed and Educated) This was a tongue-in-cheek rebuttal to the anti-vaccine propaganda booklet which circulated in our communities, which is titled PEACH, or Parents Educated and Advocating for our Children’s Health. In April, as the outbreak grew, the New York City Department of Health and Mental Hygiene (NYCDOHMH) asked our organization to prepare an abridged version of our magazine for rapid distribution. To date, close to 100,000 copies of our abridged magazine have been mailed and distributed around the United States.

Living-Room Workshops. To allow an interactive format, we hosted in-person workshops for mothers in the community. We created electronic presentations geared to parents, and nurses presented the slideshow in intimate “living-room” settings in different communities (Schaffer, 2019b). These took place in actual living rooms and school classrooms. This ensured that groups remained small and allowed for honest dialogue and questions.

To allow an interactive format, we hosted in-person workshops for mothers in the community.We brought several dozen studies with us to every session, which allowed us to review the data in person and provide visual aids. Follow up conversations demonstrated that women appreciated the opportunity to ask questions and learn about vaccine safety. Many women reported new interest in vaccinating their children. One woman took her four children for their first MMR that week, and another mother stated that while her children had been on a delayed vaccine schedule, she now planned for all of them to catch up on the required vaccinations.

Personal Attention. We published a confidential email address and phone number on all materials, giving community members an opportunity to discuss questions and concerns about vaccine safety. Forty healthcare providers have offered their time to engage in conversations with vaccine-hesitant people. To date, we have facilitated over 100 hundred phone calls and over 500 email exchanges.

We triage these calls and emails based on provider specialty. The EMES Vaccine Task Force has on call experts, including a gynecological oncologist who is most adept at speaking about the Human Papillomavirus (HPV) vaccine; a pediatric pulmonologist who is fluent regarding the flu vaccine as well as allergic conditions which are a common concern for parents; a pediatric emergency department physician who is available to discuss many childhood illness and their inherent risks; and another three dozen providers available to discuss a wide range of topics with men and women who have vaccine-related questions. Several providers are Yiddish-speaking, which has been useful considering the population we serve.

Vaccine Fairs. Rockland County, the seat of the 2018-2019 outbreak, continued to have difficulty containing the outbreak. In June 2019 we decided to host a large educational event in one Orthodox Jewish hamlet in this county. To respect the gender-segregated nature of this community, we invited women only. We used community leaders and activists as our guides when planning this event, to ensure that we met the religious and cultural standards set by this ultra-Orthodox community.

To respect the gender-segregated nature of this community, we invited women only.We reached out to local pediatricians, nurses, primary care providers, immunologists, allergists, and rabbis, requesting their support and attendance. The participating EMES nurses and physicians hosted different “vaccine booths” organized by topic. This allowed the women to have discussion with specific providers based on their concerns. All providers were required to have participated in an EMES provider workshop and were sent materials to review prior to the event. This ensured that providers were fluent in their subject matter, including autism, sudden infant death syndrome (SIDS), aluminum in vaccines, the Hepatitis B vaccine, the flu shot, and many more topics. Women moved from table to table, interacting with the providers and each other, and gathering handouts to read at home. Approximately 200 women attended this event with much positive feedback.

In June 2019, New York State passed Public Health Law S2164, (Public Health Law S2164, 2019) removing religious exemptions for vaccination as an option for schoolchildren. Many Orthodox Jewish families had used religious exemptions as a way to avoid vaccinating their families. As the summer ended, many families who had hoped for a reversal or a stay found themselves highly anxious at having to vaccinate their children or remove them from school.

We elected to hold another vaccine fair, this time in Brooklyn, the second hotbed of the measles outbreak. We followed the format of the event in Rockland County, adding some topics such as “What the Vaccine Law Means”, the HPV vaccine, and immunizations for pregnant women. This event, attended by 250 women, was an overwhelming success. Anecdotal feedback demonstrated relief from community members who appreciated unlimited time with providers who were well-versed in vaccine topics and who maintained empathy and respect throughout these conversations.

Important components of our work in this community included working with key community members who guided the work.Important components of our work in this community included working with key community members who guided the work. Women from within these communities advised us about appropriate advertising, event incentives, and dress code of healthcare volunteers. This demonstrated a respectful approach to the community we were serving.

Provider Training
While we engaged with parents using the above methods, we also received requests from providers requesting training to be able to better answer patient questions and provide vaccine education. In response, we developed a workshop geared to interested healthcare providers. The content was approved for two continuing education credits by the Northeast Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

...we also received requests from providers requesting training to be able to better answer patient questions and provide vaccine education.We hosted several provider workshops, both in-person and via livestream. These were attended by dozens of physicians, residents, interns, students, nurses, nurse practitioners, doulas, and community members who wanted to be better prepared to speak to vaccine-hesitant people in their communities (Sun, 2019). One large medical center in the Orthodox community offered us their conference space for any vaccine-related workshop we wanted to hold, even having their technical team remain late to help us livestream our event.

At these meetings, we emphasized that the crucial element in choosing to vaccinate is with the provider. A 2006 study reported that while providers indicated that they were seeing more and more vaccine-hesitant families, they also stated that they were able to convince 30% of the vaccine hesitant parents who had initially refused vaccines (AAP, 2006; Hough-Telford et al., 2016). We reviewed methods for communication as well as answers to common concerns.

...we emphasized that the crucial element in choosing to vaccinate is with the provider.Anecdotal feedback from providers demonstrated that the information provided was useful while talking to vaccine hesitant parents. Our workshops were featured in the Washington Post (Sun, 2019) and we received requests to lecture for residents at large teaching hospitals in New York City. We continued to receive positive feedback about our approach, methodology, and practical, factual presentation.

Funding
We were able to proceed with many of our projects due to generous funding from four private donors who became aware of our efforts to combat vaccine hesitancy in our community and wanted to help expand our efforts. The NYCDOHMH became a helpful ally in our work, offering to assist with printing and distribution of our magazine. The providers of the EMES group have been working on a volunteer basis and continue to do so, without remuneration.

Tips to Address Vaccine Hesitancy

Our experiences have given us lessons to share. This section offers some recommendations about what we have found that works, and also what did not work.

What Works
...as we discussed different studies and evidence, the women requested to see the studies in person.Visual Aids. Our experience has strongly corroborated that the 2-hour communication training session and the use of fact sheets were the most useful intervention components when talking to vaccine hesitant parents (Dempsey et al., 2018). For example, in this recently published study (Dempsey et al., 2018) on HPV vaccine uptake, healthcare providers were randomized into intervention groups (which included a 5-component healthcare professional HPV vaccine communication intervention) or to control groups to determine effective methods for increasing HPV vaccine uptake. All of the intervention groups reported significantly increased HPV vaccine uptake. Our first parent workshop used a slideshow presentation for this content, but as we discussed different studies and evidence, the women requested to see the studies in person. Having been told frequently that “studies have been done” they reported wanting to see the paperwork. Having learned this, we then began bringing dozens of printed studies to our workshops, allowing the women to review them.

Normalizing vaccination as the default is one way to firmly endorse the right approach and has been shown to impact how parents respond.Normalize Vaccination. There are some recommended evidence-based methods to engage with vaccine hesitant parents. Normalizing vaccination as the default is one way to firmly endorse the right approach and has been shown to impact how parents respond. One study examined different ways in which providers communicated with vaccine hesitant parents (Opel et al., 2013). Some engaged in presumptive methodology (“We have to do some shots today”) while other providers used a participatory method (“Are you comfortable giving some shots today?”). Presumptive initiation formats with vaccine hesitant parents were associated with significantly increased odds of parental agreement (89% versus 30%) when compared to participatory communication methods. Also, when providers remained firm in their recommendations despite parental resistance, nearly half of the resistant parents (47%) accepted the vaccine recommendations (Opel et al., 2013).

We empower parents to insist on good quality research and teach them how to analyze information critically...Empower Parents. We have found that parents report increased trust and confidence in their providers when they are given methods to do their own research. We include tips about how to do research and how to evaluate information in our magazine, during our workshops, at health fairs, and we incorporate these tips into our email and phone interactions with the parents (see Table 1). We empower parents to insist on good quality research and teach them how to analyze information critically, skills that most untrained people lack.

Table 1. Tips to Critically Analyze a Study

Research Concept	Tip
Sample size	Check how many people were in this study. The larger the sample size, the better.
Replication	Is this a single study, or has this been repeated? Are the findings similar? Studies that cannot be replicated are not considered valid.
Disclosures	Read the disclosures, see if the authors received funding for their work, and see if the authors may be biased.
Date	Check the date: while classic studies may be older, most good research should be published within 5-10 years.
Internet Research Tips	Avoid YouTube, social media, and websites ending in .com. Anyone can publish anything! Some websites with a .org are not trustworthy. Make sure to read the “about us” section to find out more information.

Note: Table 1 was created by the author, based on her experiences.

Communication Tips. Empathy during an emotional discussion, such as vaccinations, helps patients feel comfortable and safe to discuss their concerns. Listening and validating patients’ stories and experiences are techniques familiar to practicing nurses, and they are important when speaking to worried parents with concerns about vaccine safety. In conversations after our provider workshops ended, we learned methods which providers had found useful.

...if the atmosphere becomes tense, he stops the conversation and offers to continue speaking with the parent another time...One pediatrician shared that he only raises vaccination during sick visits, since vaccine-hesitant parents are less likely to want to vaccinate their children during illness. This way the parent may feel less pressure to agree to vaccinate and will be able to participate in the discussion more fully. Second, he recommends sitting with the patient and maintaining eye contact. Finally, he has found that if the atmosphere becomes tense, he stops the conversation and offers to continue speaking with the parent another time when both parties are calm (M. Kirschenbaum, personal communication, July 30, 2019).

...using CDC information is rarely useful in interactions with vaccine hesitant parents.What Does Not Work
Due to widespread mistrust of various medical entities, including suspicion of the Centers for Disease Control and Prevention (CDC), using CDC information is rarely useful in interactions with vaccine hesitant parents. One study examined several methods aimed at improving vaccine uptake. Some parents were given CDC information on the lack of evidence between vaccines and the development of autism. Others were given textual information on the diseases prevented by the MMR, while a third group were presented with images of children who had diseases prevented by the MMR. The final group was presented with dramatic narratives of children who died or almost died of a vaccine preventable illness (Nyhan, Reifler, Richey, & Freed, 2014). None of these methods worked to increase vaccine compliance. In fact, the group given CDC information related to vaccines and autism demonstrated decreased intent to vaccinate after their interactions with the provider. Therefore, we recommend using original sources and data when speaking to parents, and avoiding handouts, visual aids, or data retrieved from governmental health agencies.

Future Work for EMES
Our initiative has several future goals. First, we have begun incorporating outcomes measurements to evaluate if educational interventions are effective to improve knowledge regarding vaccine efficacy and safety; reduce misperceptions passed around the Orthodox Jewish communities in New York, and increase vaccination. One option for these evaluations includes the use of pre- and post-test surveys administered during workshops to evaluate knowledge deficits, or reduction in fears associated with vaccines.

Next, we plan to bring our information to our Orthodox Jewish community via podcasts or audio methods such as dial-in telephone conferences, which are accessible to a community without widespread internet access. We recognize that people have different preferences for learning, and audio methods are convenient for women who can listen while multitasking.

Additionally, we believe that buy-in from childbirth instructors will be a valuable resource for women in this community. By training doulas and instructors and help them become ambassadors for immunizations, we can encourage them to become trusted resources for their clients. Fourth, we plan to continue to provide education to healthcare providers via in-person workshops, webinars, and conferences. We have applied for and received approval for continuing education credits. Topics for continued education include best immunization practices for pregnant women; government policy and vaccination; sexuality and vaccinations; communication tips; and medical exemption guidelines.

Implications for Nurses

Nurses need to remain ongoing champions for vaccination.Nurses need to remain ongoing champions for vaccination. As front-line providers who are consistently rated as the most trusted profession in the United States (American Hospital Association, 2019), nurses who are well-versed in vaccine literacy can be reliable resources for many families. For common vaccine myths and potential responses, see Table 2. By remaining educated about relevant vaccine topics, nurses can practice evidence-based care by supporting immunization in their practice. Nurses can join efforts to engage in public health initiatives that support appropriate vaccine policies.

Table 2. Common Vaccine Concerns and Responses

Concern	The Myth	Reality	Citation
Autism	Vaccines cause autism	Dozens of studies of millions of children have failed to find any association between vaccinations and autism.	(Taylor, Swerdfeger, & Eslick, 2014)
Sudden Infant Death Syndrome (SIDS)	Vaccines increase infant mortality and cause SIDS	Studies have consistently failed to find an association between vaccines and SIDS. Some studies seem to suggest that vaccination reduces the occurrence of SIDS.	(Müller-Nordhorn, Hettler-Chen, Keil, & Muckelbauer, 2015)
Big Pharma	The pharmaceutical industry places profit above safety	Net income from vaccines represent 2% of the entire pharmaceutical industry. The rest comes from medications and devices	(Lam, B., 2015)
Adjuvants	Aluminum, formaldehyde and thimerosal are dangerous	The quantities of aluminum and formaldehyde in vaccines have been studied and were found to be safe. Thimerosal has been removed from all childhood vaccines since 2001.	(Jefferson, Rudin, & Di Pietrantonj, 2004)
Health Outcomes	Unvaccinated children are healthier than vaccinated children	Many studies have evaluated different outcomes on children who were vaccinated and unvaccinated. No differences in their health have ever been found.	(Schmitz, Poethko-Müller, Reiter, & Schlaud, 2011).

Nurses who are active on social media should continue to promote good health and immunization by engaging in online discussions about the benefits of vaccinating (Danielson, Marcus, & Boyle, 2019). Organizations such as Nurses Who Vaccinate (n.d.) and Voices for Vaccines (n.d.) support nurses who want to become vaccine champions. These organizations provide nurses with evidence-based information about vaccines, communication techniques, opportunities for political advocacy, and more.

Conclusion

Vaccine hesitancy continues to be a growing global problem...Vaccine hesitancy continues to be a growing global problem, with resultant increases in vaccine-preventable infectious diseases. There has been a collapse of trust within the healthcare delivery system. According to Gallup Polls, confidence in the medical establishment has fallen from 80% in 1975 to 37% in 2015 (Baron, 2019). Healthcare has grown and become more impersonal; many feel that care is driven by profits; and the digital age has brought complex information, often confusing, straight to consumers (Baron, 2019).

Misinformation, the use of social media, and the elimination of many infectious diseases together with the collective short-term memory of many people contribute to a reluctance to immunize. Healthcare providers of various disciplines must continue to work together to increase outreach and education. They need to remain aware of current trends in vaccine hesitancy and be able to respond in kind by assisting in vaccine education, supporting relevant policies, and supporting the evidence wherever they practice.

Being fluent in vaccine science is important when speaking to vaccine-hesitant parents, but the delivery method of information must also be thoughtfully intentional. Considering the cultural background of the parents, their health literacy, and using common sense therapeutic communication can help ensure that parents feel heard and respected. This may increase the level of trust in their provider. Public health officials can and should use community partners who are trustworthy, and form relationships with them to improve immunization levels in vulnerable communities.

Author

Blima Marcus, DNP, RN, ANP-BC, OCN
Email: bmarcusrn@gmail.com

Blima Marcus received her undergraduate nursing degree from the New York University School of Nursing in 2010 and her doctorate degree in nursing from the Hunter-Bellevue School of Nursing in 2018. She is a nurse practitioner at the Memorial Sloan Kettering Cancer Center, and an Assistant Adjunct Professor at the Hunter-Bellevue School of Nursing. She is a member of the Oncology Nursing Society, Sigma Theta Tau International Honor Society for Nursing, and the American Nurses Association. She served as President of the Orthodox Jewish Nurses Association and as Editor of the OJNA Journal. She is the President of the EMES Initiative, Inc, a non-profit organization dedicated to advancing healthcare education for communities with healthcare information barriers. She lives in Brooklyn, New York.

---