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The new school year is here, and if history repeats itself, vaccination rates will continue declining and exemptions rising.

It can translate to a difficult office visit for primary care physicians trying to keep their patients as healthy as possible. Among US kindergartners, vaccination coverage decreased for all reported vaccines during the 2024-2025 school year compared with the year before, according to CDC data. An estimated 286,000 kindergartners attended school last year without completing the measles-mumps-rubella (MMR) series — and 1356 confirmed measles cases have been reported this year as of August 6.

We asked four primary care doctors from four different states to share their scripts and tips for the often-difficult vaccination conversation.

Carlos O’Bryan-Becerra, MD: Repeat, Repeat, Repeat. Plant the Seed

An obstetric patient was positive for hepatitis B virus (HBV) and a vaccine skeptic.

Both the mother- and father-to-be were against giving the baby the hepatitis B vaccine.

“We know the risk of transmission is high,” O’Bryan-Becerra, a family physician in Ventura, California, and a core faculty member of the Ventura County Medical Center residency program, told the couple.

He explained a vaccination is routinely recommended for all infants at birth, and that hepatitis B immune globulin is also recommended for infants whose mother is infected with HBV to reduce the risk of the infant becoming infected during the pregnancy or at delivery. He pointed out that an infant who contracts hepatitis B has a higher risk of later getting cirrhosis and cancer.

Still, the couple refused the vaccine when the newborn arrived. “They said many doctors didn’t believe [it was needed] and that big pharma was behind why we vaccinate babies,” said O’Bryan-Becerra.

He kept trying, stressing the facts and that he vaccinated his own children. In the end, he was able to convince them.

“We got guidance from the [hospital] ethics committee,” he said. “In some states, there is a lot more leniency [for exemptions]. In California, there are medical exemptions only.” There was no validated medical information that would point to a need for a medical exemption. “So, the vaccination was clearly standard of care,” said O’Bryan-Becerra.

He said that if the parents were not willing to follow the standard of care, he would have to reach out to child protective services. “When I brought this up, the parents decided they were willing to go ahead and vaccinate the child.”

“I’ve been practicing 17 years and never had a scenario like this,” he said. He plans to continue talking to reluctant parents, visit after visit. He tells them: “I know you’re sick of me talking about this. But you know I bring this up because I care.” He may not convince them at that visit, but he hopes he is at least planting the seed.

Emily Briggs, MD, FAAFP: Meet the Patients Where They Are

Meeting the patient who is hesitant about vaccines where they are — and understanding where they got their vaccine information — is uppermost in the mind of Briggs, honorary FACOG, a private practice family physician in New Braunfels, Texas.

Recently, a parent shared an unbelievable reason for declining a vaccine for her child: “I saw if I give this vaccine to my child, it’s going to make spoons stay attached to her,” she said. She elaborated, “My child will become magnetized.”

Briggs got to the source of the misinformation — a social media post. “I went and looked for it,” Briggs said. It turned out the original post wasn’t about a childhood vaccine but the COVID vaccine, and the claim had circulated widely in 2021, along with other false claims about the vaccine. At the time, the CDC debunked it quickly.

Briggs told the mother what was in the vaccine her child needed and talked about decades of research on safety and effectiveness. She talked about the danger of misinformation and that some studies have been retracted or that claims on social media have been debunked.

She often points to the retraction, in 2010, of the Andrew Wakefield research falsely claiming a link between the MMR vaccine and autism, first published in 1998 and later disproven. While it happened years ago, Briggs said she brings it up because parents who are unaware of the retraction still do.

The parent with the magnetizing concerns agreed to let her child receive some vaccines that day. “A month later, they came for the other half of the 2-month-old vaccines,” said Briggs, who agreed to that schedule. “When parents can see my humanity meeting their humanity, and that we both have the best intent, we can often find common ground,” Briggs said.

Brent Smith, MD, MSc, FAAFP: Watch the Body Language

Pushback about mandates for COVID vaccines “has trickled over into all vaccines in this area,” said Smith, a family physician in Greenville, Mississippi, and a board member of the American Academy of Family Physicians.

When parents arrive at his office with a child due for an immunization, he has learned to watch the body language. When the conversation focuses on vaccines, those who are hesitant often will tense up, he said. “Their body language will change, or they will become a little more guarded.”

Recently, when the parent of a 2-year-old brought her in for a yearly checkup, Smith reminded her that the child was behind on routine vaccines. The mother’s body language changed, so he asked immediately what she’d heard that was making her uncomfortable. Most often, it’s misinformation from friends or the internet.

“You have to address it step by step,” he said, telling them what the truth is. Addressing the misinformation directly and providing them with facts can give them a different perspective.

The mother was strongly against the COVID and flu vaccines, in particular. Smith explained the differences between COVID and flu and their vaccines but decided for this visit to focus on the other recommended vaccines, especially as flu season was done. When Smith focused on the other vaccines that the mother didn’t oppose as strongly, the mother agreed for her child to catch up with the diphtheria-tetanus-pertussis, MMR, and hepatitis A vaccines.

Smith said he’s learned to keep perspective. “Sometimes you have to compromise and say, ‘What’s the most important thing I can address or get done today?’”

James B. Bigham, MD, MPH, FAAFP: ‘Assume It’s a Yes’

In years past, pre-pandemic, physicians and patients often just assumed they’d get recommended vaccines, said Bigham, a clinical professor of family medicine and community health at the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. “That’s changed. People are opting out for various reasons.”

So, it’s crucial, he said, to demonstrate confidence about vaccines — and to assume the answer will be yes. He calls it “having a presumptive approach.” When a patient comes in and is due for a vaccine, he tells them: “Today is a good day to give the vaccine.”

If there’s pushback, he said, it’s important to listen to the questions. He repeats his recommendation and describes the illness the vaccine is designed to prevent.

For instance: “I strongly recommend you receive the influenza vaccine because it could make you really sick…and you might miss a couple weeks of work, or your child might miss a week or 2 of school.”

Consider that some parents have no firsthand experience with some vaccine-preventable illnesses, he said, and that could explain their hesitancy. They wonder what chickenpox is, for instance, since they got the vaccine as children and have never seen a case.

He takes time to answer those questions. “It’s so important now not to be dismissive,” he said.

O’Bryan-Becerra, Briggs, and Smith reported having no disclosures. Bigham disclosed having relationships with Pfizer, Moderna, Valneva, Dynavax, and Seqirus.