The vaccine battle wages on, and more and more pediatricians are refusing to put up with it.

According to a survey of pediatricians released today in The Journal of Pediatrics, the number of doctors who report dismissing families from their practice for refusing vaccines has nearly doubled between 2006 and 2013, from 6 percent to about 12 percent.

And in an accompanying report also released today, the American Academy of Pediatrics (AAP) concedes that this can be an “acceptable option” when all other efforts to persuade parents to vaccinate have failed.

Previous statements have been more circumspect, advising that pediatricians “endeavor not to discharge patients from their practices solely because a parent refuses to immunize a child.”

Most pediatricians surveyed had encountered families suspicious of vaccines, reporting that about 1 in 5 parents asked to delay at least one shot.

Read more: Understanding opposition to vaccines »

Hesitant parents

The reasons behind that hesitancy appear to be shifting slightly, the doctors reported, from concern over side effects to the belief that the shots just didn’t seem necessary.

“We’re certainly glad that we have done such a good job of reducing so many diseases so that they’re not very common, but we also know that diseases are an airplane ride away,” Dr. Kathryn Edwards, a pediatrician and vaccine researcher who co-wrote the vaccine hesitancy guide, told Healthline.

In the guide, Edwards and her co-authors advise doctors to listen to parents and treat their concerns seriously, then explain how vaccines are tested for safety and how grave the illnesses they prevent can be.

“I’ve been a pediatrician now for 40 years and the last night I was a pediatric resident many, many, years ago I watched a beautiful little toddler die of meningitis,” Edwards said. “There was nothing that I could do to save that baby. And now we have a vaccine and we hardly ever see that kind of meningitis. It is just gone.”

Younger doctors who haven’t seen these illnesses would benefit from training and role-playing conversations about vaccines during medical school and residency programs, Edwards said.

According to the doctors surveyed, about a third of reluctant parents can be persuaded to vaccinate after this kind of discussion.

When this fails, doctors report dismissing patients not just because of the impaired relationship, but also out of concern for the safety of other children who visit their office. Should an unvaccinated child come down with measles, for example, they could spread it just by sneezing in a doctor’s waiting room.

But doctors should not do this if the child can’t get adequate care elsewhere, or if state laws prohibit “abandonment” of patients, the guide says.

Read more: CDC continues aggressive push for HPV vaccination for preteens »

No exemptions

The third of the trio of vaccine-related papers published by the AAP today is directed at policymakers.

It is a firm statement against exemptions to requirements that children be vaccinated before attending school or day care.

All 50 states as well as District of Columbia have these requirements, but many allow religious or philosophical exemptions.

While exceptions for children who can’t be vaccinated for medical reasons are legitimate, “nonmedical exemptions to immunization requirements are problematic because of medical, public health, and ethical reasons, and create unnecessary risk to both individual people and communities,” the authors, who make up various AAP committees, write.

A review from earlier this year found that many of those who were infected during measles outbreaks since 2000 were intentionally unvaccinated.

Outbreaks of whooping cough, too, seemed to have an association with vaccine refusal, although the limited effectiveness of the second generation of that vaccine complicates the issue.

While vaccination rates across the board are pretty stable in the United States, the authors note that unvaccinated children tend to cluster in specific communities, leading to “hotspots” of disease transmission.

One study from last year found that almost a quarter of the children in a Vallejo, California, neighborhood were undervaccinated — putting that community at a higher risk for an outbreak of a disease like measles.

The best solution to “vaccine hesitancy,” a phrase invented to acknowledge the spectrum of attitudes about vaccines, may be as low-tech as face time with a patient, caring doctor.

Parents still see doctors as one of the best sources of information about vaccines, according to a 2009 study.

Doctors should take the time to discuss the benefits of vaccines and assuage concerns about risks, Edwards and her colleagues write. They should also point parents in the direction of trustworthy sources of information about vaccines, including sites run by hospitals that are “child-based, not government-based,” Edwards said.

Taking that time in the doctor’s office might be just the thing to avoid the unpleasant and ethically sticky decision to turn patients away.