Open Journal of Pediatrics, 2012, 2, 228-235 OJPed
http://dx.doi.org/10.4236/ojped.2012.23036 Published Online September 2012 (http://www.SciRP.org/journal/ojped/)
Vaccination practices among physicians and their children
Michael Martin1, Vahe Badalyan2
1Department of Pediatrics, Inova Fairfax Hospital for Children, Falls Church, USA
2Department of Gastroenterology, Children’s National Medical Center, Washington DC, USA
Received 1 May 2012; revised 3 July 2012; accepted 30 July 2012
ABSTRACT
The purpose of this study was to identify vaccination
patterns of both general pediatricians and subspe-
cialists with regards to their own children and pro-
jected progeny. A 14 question survey was sent ran-
domly to 1000 members of the Academy of Pediatrics
in 2009. Two categories of questions included 1) how
physicians with children vaccinated them in the past,
and 2) how all respondents would vaccinate a child in
2009. A comparison was made between the answers of
general and specialty pediatricians. 582 valid ques-
tionnaires were received (58.2% response rate) of
which 431 were general pediatricians and 151 sub-
specialists. No statistical difference was found be-
tween general and specialty pediatricians on how they
vaccinated their children up until 2009 (95% vs 93%).
When asked about vaccinating a future child, a sig-
nificant proportion of respondents would deviate
from CDC guidelines, specialists more than general
pediatricians (21% vs 9%). Generalists were more
likely to give a future child Hepatitis A (OR: 3.6; 95%
CI 1.3 - 10.4), Rotavirus (OR: 2.2; 95% CI 1.1 - 4.4),
Meningococcal (OR: 9.9; 95% CI 3.3 - 29.9), and in-
fluenza (OR: 5.4; 95% CI 1.1 - 26.7) vaccines. Spe-
cialists were more likely to postpone MMR vaccine-
tion (OR: 4.4 95% CI 2.3 - 8.6). Safety was listed by
both groups as the most common reason for altering
the recommended immunization schedule. Until 2009,
general pediatricians and pediatric specialists have
largely adhered to ACIP recommendations, but due
to vaccine safety and other concerns, both groups,
albeit a higher percentage of specialists, reported
greater numbers willing to diverge from these rec-
ommendations.
Keywords: Vaccination; Vaccine Adverse Events;
Vaccine Schedule; Pediatricians; Preventable Diseases
1. INTRODUCTION
While parents seek information from many sources, phy-
sicians remain the most commonly relied on resource of
information regarding immunizations [1]. Health care
providers influence the rates of immunization by an-
swering parents’ questions, addressing misinformation,
and ultimately building trust [2-4]. Parents who change
their mind from delaying or refusing vaccines for their
child most often credit the child’s health care provider
for this change [5]. This places the pediatrician in a
unique position to influence vaccination patterns in the
United States.
How pediatricians choose to vaccinate their own
children may provide the closest surrogate for their
actual beliefs on both the necessity and benefits of
immunization and ultimately how they counsel families.
Little is documented, however, on how pediatricians
vaccinate their children overall [6]. One study in 2005
examined how 93% of Swiss physicians followed im-
munization recommendations in that country, but no
duplicate study has been performed in the United States
to date [7]. A number of prior studies have examined
reported acceptance of new vaccines including rotavirus,
but not their acceptance of the overall vaccine schedule
of the Advisory Committee on Immunization Practices
(ACIP) [8-11]. Gust and colleagues in 2008 surveyed
largely family practitioners and a smaller number of
pediatricians and found 11% do not recommend to
parents that children receive all available vaccines [12].
Barriers to acceptance have included safety, cost, reim-
bursement, parental acceptance, as well as a perceived
lack of need for a vaccine [8-11]. It is important to first
identify physicians’ beliefs on vaccines in order to im-
prove the counseling they give to families.
Our study was designed to compare how those physi-
cians involved the most with vaccination, namely general
pediatricians, compared to pediatric subspecialists, who
were less familiar with both vaccine preventable illnesses
and the vaccines themselves, in vaccinating their own
children as well as future progeny. It was surmised that
those persons most familiar with vaccines would be more
likely to fully vaccinate their own children. We also ex-
amined which vaccines were most often not given or
would not be given to future children.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 229
2. PATIENTS AND METHODS
1000 web based questionnaires (Figure 1) were sent to a
randomized list of members of the Academy of Pediat-
rics (AAP). An estimated 80% of board certified pedia-
tricians are members of the AAP. Included in responses
were general pediatricians and pediatric subspecialists
currently in the United States. The list of participants
was generated from the AAP member directory and
every 20th name selected alphabetically at random to
participate. If the randomized name did not have a
working email or mailing address, the next name in the
list was used. This occurred in 11 cases. 223 of those
emailed responded to the initial email and 55 responded
to the 2nd email sent out 3 weeks later. The 722 non
responders were sent a questionnaire by mail 3 weeks
following the 2nd email request with a $2 incentive
enclosed in the envelope as well as a stamped envelope
for return of the survey. A total of 657 surveys were
completed in all. All responses were anonymous.
1. You are a:  Male  Female
2. In which state do you primarily practice?
3. Which best describes you?  General Pediatrician  Pediatric Subspecialist  Family Medicine Physician  Other: _____
4. When did you complete medical school?
 After 2004  2000-2003  1990-1999  1980-1989  1970-1979  1960-1969  Before 1960
5. You work: (check all that apply)
 in private practice  in community clinic  at a hospital  in public administration  for the government
 in school of medicine  in the pharmaceutical industry  other professional area
6. Do you have children?  Yes  No (if no, go to question 12)
7. How many children do you have?  1  2  3  4  5 or more
8. What ages are your child(ren)? (check all that apply)  < 2 years old  2 - 4 years old  5 - 10 years old  > 11 years old
9. Did you follow the up-to-date recommended vaccination schedule annually published by the Advisory Committee for Immunization Practices
(ACIP) for all of your children as it was written at the time they were vaccinated?
 Yes (if yes go to question 12 )  No  I did not know or refer to the guidelines
10. If you did not elect to follow the vaccination schedule or followed an alternative schedule, which vaccines did you elect to postpone or not
give? If a vaccine was not available when your child was vaccinated, do not check
it. (check all that apply)
 DTaP  Hib  Prevnar  IPV  Rotavirus  Hep A  Hep B  MMR
 Varicella  Meningococcal (Menactra)  Influenza
11. If you elected to not give a vaccine, or to postpone it, which reasons best describe why. (check all that apply)
 Medical contraindication
 Too many vaccines given at once
 Safety concern
 Vaccine protects against illness that does not present a risk to your child
 Do not believe in efficacy of vaccine
 Other (Please explain):______________________________
12. If you were a “new parent” in 2009-2010, at what age would you give the first dose of MMR to your own children?
 < 18 months old  18 months - 2 years old  3 - 5 years old  6 - 10 years old  11 - 15 years old
 > 15 years old  would not vaccinate
13. If you were a “new parent” in 2009-2010, which vaccines would you NOT give to your own children? (check all that apply)
 None - I would give all of them  DtaP  Hib  Prevnar  IPV  Rotavirus  Hepatitis A
 Hepatitis B  MMR  Varicella  Menactra  Influenza  Other (please specify) ________________________
14. If were a new parent in 2009-2010 and would not give a vaccine, which reasons best describe why. (check all that apply)
 Medical contraindication  Too many vaccines given at once  Safety concern
 Vaccine protects against illness that does not present a risk to the individual  Do not believe in efficacy of vaccine
 Other (please explain)________________________________________________________________________
Figure 1. Survey sent to physicians.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 230
The 14 question survey was presented on 6 separate
pages as a web survey or a single page as a mailed sur-
vey. Questions were divided into 3 distinct sections: 1)
gathering demographic information; 2) parent physicians
were asked how they vaccinated their own children and
if not following recommended schedules for which vac-
cines and why; and 3) all participants were asked what
vaccines they would or would not give to a hypothetical
new child. In addition to set responses for skipping or not
giving a vaccine, open fields were included to allow for
participants to provide answers not included in the op-
tions given. Web surveys were entered by participants
into Survey Monkey and mailed surveys manually en-
tered into this same program and exported to Microsoft
Excel.
Using standard descriptive statistics, demographic
characteristics of responding participants is shown in
Table 1. Comparisons of baseline demographics and
immunization measures were performed by using
chi-square tests where appropriate. Univariate statistical
analyses were performed for each variable to determine
its relationship to the main independent variable, being a
general pediatrician or subspecialist. Logistic-regression
analysis was used to calculate the adjusted odds rations
(OR) and 95% confidence interval (CI), controlling for
any statistically significant demographic variables that
might act as a confounder. Differences were considered
significant at P < 0.05 and when the 95% CI did not in-
clude 1.0. SPSS statistical software version 18 (SPSS,
Inc., Chicago, IL) was used for the statistical analysis.
3. RESULTS
Of the 1000 surveys sent, a total of 582 were utilized in
our analysis. 75 participants did not fit the categorization
as a pediatric specialist or general pediatrician and were
excluded from analysis. These included 5 family physi-
cians, 33 residents, and 37 persons designating them-
selves as “other” who could not be categorized. Of those
surveys analyzed, 431 were completed by general pedia-
tricians and 151 completed by pediatric subspecialists.
Subspecialists included a wide representation including
pediatric cardiology, urology, neonatology, and even
toxicology. Table 1 summarizes the demographic char-
acteristics of the participants. General pediatricians were
more likely to be female (57%) than subspecialists (40%)
and more likely to work in the outpatient setting (73%
versus 21%).
Table 1. Characteristics of physicians responding.
General Pediatrician (n = 431) Pediatric Specialist (n = 151) Chi squarea P value
Gender (female) 57% 40% 14.06 0.00
Region:
Northeast 25% 18%
Southeast 37% 33%
Midwest 17% 28%
West 21% 21%
9.40 0.02
Type of activity:
Outpatient 73% 21%
Hospital 15% 45%
Government 2% 3%
Medical School 6% 28%
Other 5% 3%
147.57 0.00
Year of medical school completion:
After 2004 17% 6%
2000-2003 13% 14%
1990-1999 32% 27%
1980-1989 20% 25%
1970-1979 11% 20%
1960-1969 4% 8%
Before 1960 2% 0%
23.97 0.00
Has children 78% 85% 2.82 0.09
aUsing two-way tables with measures of association.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 231
Overall, out of 466 respondents who reported having
children, 438 (94%) stated that they followed ACIP
recommendations regarding vaccination. This rate was
slightly higher among general pediatricians (95% vs 93%)
but the difference was not statistically significant. Over-
all rates for individual vaccines were considerably high
ranging from 97% to 100% for both general pediatri-
cians and specialists (Table 2). The lower rate of overall
compliance with the ACIP recommendations is likely
accounted for by differences among which vaccines phy-
sicians elected to skip for their children. One notable
trend, however, was that physicians who graduated from
medical school prior to 1990 were less likely to vaccinate
their own children for rotavirus (OR: 10; 95% CI: 1.1 -
81 P value 0.038).
When asked about how they would vaccinate a poten-
tial child in 2009, larger differences emerged between
general pediatricians and specialists (Table 3). Respon-
dents included both those who have and do not have
children (n = 554). Specialists were found to be less
likely to follow the overall schedule. 41 generalists
(9.9%) and 29 specialists (21%) reported they would skip
at least one vaccine for their future child (Chi square =
0.001). Specifically, generalists in 2009 were more likely
Table 2. Reported vaccination practices of respondents who have their own children.
Generalist (n = 336) Subspecialist (n = 128)P value Adjusted ORa 95% CIb
Followed ACIP recommendation 95% 92% 0.39 0.7 0.3 - 1.7
DTaP 100% 100%
Hib 100% 100%
Pneumococcal 100% 99% 0.79 1.5 0.1 - 27.9
IPV 100% 99% 0.88 1.3 0.1 - 25.9
Rotavirus 98% 98% 0.60 0.6 0.1 - 3.4
Hepatitis A 99% 98% 0.64 1.4 0.3 - 6.9
Hepatitis B 99% 99% 0.55 0.5 0 - 5.5
MMR 98% 100%
Varicella 99% 97% 0.39 1.9 0.4 - 8.8
Meningococcal 100% 98%
Influenza 99% 99% 0.51 0.5 0 - 4.8
aUsing binomial regression model, controlling for the following independent variables: speciality (generalist vs specialist), gender, graduation year (after 1990
or before), living in western states (yes, no), practicing in hospital (yes, no). bOR and CI not calculated if the % of one of the outcomes of the dependent vari-
able was ≤1%.
Table 3. Projected pattern of vaccination of all respondents.
Generalist (n = 416)Subspecialist (n = 138) P value Adjusted ORa 95% CIb
Would postpone MMR until after 18 months 5% 19% 0.00 4.4 2.3 - 8.6
Would not give DTaP 0.5% 0%
Would not give Hib 0% 0%
Would not give Prevnar 0.7% 0%
Would not give IPV 0.2% 0%
Would not give Rotavirus 6% 12% 0.03 2.2 1.1 - 4.4
Would not give Hepatitis A 2% 6% 0.02 3.6 1.3 - 10.4
Would not give Hepatitis B 0.2% 1% 0.83 1.4 0.1 - 28.4
Would not give MMR 1% 1% 0.83 0.8 0.1 - 8.7
Would not give Varicella 1% 2% 0.30 2.3 0.5 - 11.6
Would not give Menactra 1% 9% 0.00 9.9 3.3 - 29.9
Would not give Influenza 1% 3% 0.04 5.4 1.1 - 26.7
Would not give Gardasil 1% 1% 0.57 0.5 0.1 - 4.8
aUsing binomial regression model, controlling for the following independent variables: speciality (generalist vs specialist), gender, graduation year (after 1990
or before), living in western states (yes, no), practicing in hospital (yes, no). bOR and CI not calculated if the % of one of the outcomes of the dependent vari-
able was ≤1%.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 232
to give a future child Hepatitis A (OR: 3.6; 95% CI 1.3 -
10.4), Rotavirus (OR: 2.2; 95% CI 1.1 - 4.4), Meningo-
coccal (OR: 9.9; 95% CI 3.3 - 29.9), and Influenza (OR:
5.4; 95% CI 1.1 - 26.7) vaccines. Pediatric specialists
reported a stronger desire to postpone future MMR vac-
cination (OR: 4.4 95% CI 2.3 - 8.6), but even 5% of
general pediatricians reported they also would postpone
this vaccine beyond 18 months. Of the respondents who
would elect to withhold at least one vaccine for future
progeny (63 of 70 who actually reported having children),
the most common reason given was “safety” and “too
many vaccines given at once” (Table 4). This pattern
was also seen for those respondents who have children
and elected not to receive vaccines as recommended by
the ACIP (Table 5). Place of work such as in “private
practice” or “for the government” did not demonstrate to
play a role in choosing to vaccinate in either specialists
or generalists.
Table 4. Physicians’ reasons for withholding immunization of future progeny.
Generalist (n = 41) Subspecialist (n = 29)
Medical contraindication 1 (2.4%) 1 (3.4%)
Too many vaccines given at once 4 (9.8%) 3 (10.3%)
Safety concern 12 (29.3%) 12 (41.4%)
Do not believe in efficacy of vaccine3 (7.3%) 2 (6.9%)
Other
“In developed countries Rotavirus is for the most part treatable and I’ve seen some side effects.”
“Rotavirus is negligible in US. More of a problem in 3rd world but vaccine ineffective there.”
“Very low incidence; vaccination not warranted (Hep A).”
“(Gardasil) is not appropriate for USA population, doesn’t remove need for exams, better served in other
parts of world.”
“Not important (Gardasil) to my daughter and presumes promiscuity.”
“Not convinced of need (Hep A).”
“1) A newborn does not need Hep B, 2) Hep A is rare in US, and 3) Rotavirus is too new.”
“Would not bundle vaccines.”
“New to the market, awaiting long term research (Gardasil).”
“Children got H1N1 and protected from disease.”
“No need to introduce another potentially confounding variable until development is clearly normal. Poor
science but good art. (regarding delay of MMR).”
“Feel HAV us unnecessary at that age.”
“Risk is greater than negligible benefit in my family situation (rotavirus).”
“Severity of illness does not warrant vaccination (rotavirus).”
Table 5. Physicians’ reasons for withholding immunization of their own children (those who actually have children).
Generalist (n = 15) Subspecialist (n = 9)
Medical contraindication 1 (6.7%) 0
Too many vaccines given at once 3 (20%) 3 (33%)
Safety concern 3 (20%) 3 (33%)
Do not believe in efficacy of vaccine2 (13%) 1 (11%)
Other
“Wanted to see if [child] got chickenpox and ensure lifetime immunity.”
“Knew baby at low risk [for hepatitis B] at birth, decided to start series at 2 mos checkup.”
“Not in school,limited exposure,able to space them out.”
“Risk exceeds benefit in my family (stay at home parent).”
“Illness itself is usually not severe enough to warrant vaccination (i.e., rotavirus).”
“One child on chemo; other was PDD; other two got everything on schedule.”

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 233
4. DISCUSSION
Until now few studies have examined how pediatricians
in the US vaccinate their own children [6,7]. The results
of this study bridge this gap by confirming that a high
percentage, 94% of respondents, vaccinated their own
children according to ACIP recommendations through
2009 and will likely continue to do so in the future. This
important message of “lead by example” should be
communicated to a public who is increasingly concerned
over the need and safety of vaccines. For those charged
with vaccinating and caring for children, there is a strong
uniformity with respect to their own children in the
actual practice of immunizing as per ACIP recom-
mendations. One of the most common questions asked to
pediatricians is “what would you do with your child?”
This study answers this question.
Pediatric specialists and general pediatricians do ap-
pear potentially poised to diverge further from ACIP
recommendations with future progeny. This trend was
much larger in the subspecialist group. This may be due
to the greater ignorance of subspecialists with regards to
the vaccines and the diseases they prevent. Future studies
might look to correlate the specialty with electing not to
give certain vaccines. Those physicians responding they
would not follow recommendations cited safety as their
largest concern. This parallels the trend of increasing
safety concerns by parents [13-15]. Reasons for safety
concerns given by physicians ranged from claims of vac-
cines being “too new,” of perceived “risk” being “greater
than [the] negligible benefit,” and even a perceived
“risk” in bundling vaccines (Tables 4 and 5).
A significant number of subspecialists did not want to
give hepatitis A (6%), rotavirus (12%), and meningo-
coccal vaccine (9%) moving forward. Comments of
those who would not give hepatitis A included “[I am]
not convinced of the need”, “[I] feel Hepatitis A vaccine-
tion is unnecessary at that age”, “severity of [the] illness
does not warrant vaccination”, and the “risk exceeds the
benefit in my family (stay at home parent)”. Despite
evidence of the enormous cost savings and reduction in
rotavirus morbidity and incidence in the United States,
many physicians in the study appeared to feel that rota-
virus vaccination at the individual level was not appro-
priate in their future progeny [16,17]. It may be that
those physicians who practiced in 1999 are biased
against the rotavirus vaccine having witnessed the recall
of the rotavirus vaccine, Rotashield, due to an associa-
tion with intussusception. Older physicians, those gradu-
ating prior to 1990, in our study demonstrated to be less
inclined to vaccinate with rotavirus compared to their
younger counterparts. With meningococcal vaccine, safety
again was observed to be the major barrier that needs to
be addressed with pediatric specialists. The most signifi-
cant differential between projected immunizations of
children of general pediatricians versus specialists was
with meningococcal vaccination. This possibly reflects
the greater exposure of general pediatricians with the
serious outcomes of the disease caused by this organism.
What is observed from this study is the intent of some
general pediatricians (5%) and a higher proportion of
specialists (19%) to delay the MMR vaccination beyond
18 months of age despite recent increases in incidence of
Measles disease [18]. This is somewhat unexpected
given the time and resources spent to discredit any asso-
ciation between MMR and autism, but it does mimic the
public trend. One physician even goes so far to comment
that there is “no need to introduce another potentially
confounding variable (MMR vaccine) until development
is clearly normal.” This potential trend represents a ma-
jor threat to effectively combating the current rise in
measles. Such physicians may not feel compelled to ar-
gue for timely vaccination with MMR.
Electing not to vaccinate leads to poor outcomes for
many. In a retrospective cohort study spanning 10 years,
unvaccinated children were found to be 22 times more
likely to contract measles and 6 times more likely to
contract pertussis than vaccinated children [19]. In 2008,
the most measles cases since 1996 occurred. 112 of a
total of 131 cases were unvaccinated or had unknown
vaccination status [20]. In 2009, approximately 0.6% of
children between 19 and 35 months received no vac-
cinations and represents an increase from 0.4% from
2006 [18]. Despite these trends, delaying MMR vac-
cination based on our findings may increase among pedi-
atric clinicians.
Our results did show some methodological limitations
necessitating caution in interpreting them. Recollection
bias may have influenced answers that relied on phy-
sicians’ recall of past vaccine practices. Also, answers
for a hypothetical child, may not necessarily translate
into actions once a physician has an actual child. This
survey drew from a pool of pediatric providers who were
far more likely to be interested in vaccine issues as
immunization of all children is a primary stated goal of
the AAP. This suggests that compliance of the survey
respondents in vaccinating their own children according
to ACIP guidelines will be higher than for the general
population of pediatric providers in the US. The survey
also did not address whether responders were actively
charged with vaccinating patients. It is not known
whether those working “for the government” or “in a
school of medicine” actually vaccinate children in their
workplace. It is also possible that questionnaires were
sent to pediatricians who were parents of the same child
although no physicians bearing the same last name who
completed the questionnaire were located in the same
state. Unfortunately, from the database it was not possible
to elicit relationships of physicians surveyed.

M. Martin, V. Badalyan / Open Journal of Pediatrics 2 (2012) 228-235 234
While most pediatricians and pediatric specialists
(95% and 93%) have adhered to the recommended ACIP
vaccination schedule up until 2009, a potential for change
emerged with 10% of pediatricians and 21% of pediatric
specialists claiming they would not follow the recom-
mendations for future progeny. Despite their education,
physicians in this study expressed concern over the
safety of vaccines. This study points to the need to focus
on education efforts, including safety data, for those
particular vaccines physicians displayed the greatest
concern over including hepatitis A, rotavirus, meningo-
coccal, and measles. Pediatric specialists should be in-
cluded in this education as they have the greatest
concerns, may be the most removed from the diseases
protected by the immunizations, but also care for some
of the most vulnerable populations. It has been shown
that the more convinced physicians are of the benefits of
vaccines, the more likely they are to immunize their
patients [21-23].
Researchers might look to correlate whether patients
of physicians who choose not to follow current recom-
mendations are indeed more likely to also not follow the
published schedule. Continued control of communicable
disease will rely on the success of efforts to educate the
public and physicians. Future study should thus focus on
how to best address safety concerns which presents the
greatest threat to sustained high vaccination level.
5. ACKNOWLEDGEMENTS
An educational grant for this study was provided by Inova Health Sys-
tems.
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