time-efficient skills to address vaccine-hesitant parents · at the conclusion of the webinar,...

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Time-Efficient Skills to Address Vaccine-Hesitant Parents:

Focus Group Results and Best Practices

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Is there any way to put a screen shot in here to help people know where / how they can ask a question?

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ObjectivesAt the conclusion of the webinar, participants will be able to:

•Recognize three factors influencing vaccine safety concerns

•Identify two key parent perspectives on vaccine messaging

•Create effective fact based messages to use in practice and media settings.

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Setting the Stage for Good Communication:

Parental Concerns About Vaccines

Kris Calvin, MPHCEO, AAP-

CA

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A Long History

Concerns about vaccines have been around  since  they first were developed. Ben Franklin  

in the 18th

century was  a fervent anti‐vaccine   proponent until his 4‐yr old son died of 

smallpox, after which he said:“…I long regretted bitterly, and still regret that 

I  had not given it to him by innoculation…”Healy & Pickering  Pediatrics Online 4‐18‐2011

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2009 Pediatrician Focus Groups by AAP‐CA  (CDC‐funded)—Perceived  Parental Concerns

•

Autism •

Thimerosal

(mercury)

•

Aluminum•

Pain from shots, “minor”

reactions

•

Number of shots•

Newness of vaccines/not properly tested 

(HPV)•

Belief that  risk of disease  is near‐zero

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2012 Parent Focus Groups  (First 5 OC‐funded)

•

Call themselves “vaccine‐educated”

•

Not “anti‐vaccine”—parents themselves seek  out vaccinations

•

Many  do not name autism as concern  (although may be implicit); may be “insulted if  

MD thinks they believe in this link.

8

More…

•

Mama Bear/Papa Bear —NOT concerned  about public health/responsibility is only to 

protect their own child.

•

Compare their child’s “rosy cheek” unvaccinated health (I never have to see a 

doctor) with  those they perceive as “often  sick”

that have been vaccinated.

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2012 groups (cont)•

Concern over “developing immune system”—

# of shots/antigens,  desire for “green”

shots  (no formaldehyde,etc)

•

Belief that getting a disease “naturally”

is  better, creates  stronger immunity

•

Belief they understand science better then  scientists, since they are “unbiased”, not 

influenced by $$ 

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Ongoing  across time

•

Still core problem that they have not seen and do  not fear vaccine‐preventable  diseases

•

Subset of chiropractors, alternative providers  highly influential  

•

Selected shots concern them  ‐‐MMR ,varicella HPV, Hep

B at birth

•

Loving parents—some fearful, some “know‐it‐ all”, but by and large all  concerned most with  their child’s welfare.

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Their Solution?* Refuse/delay/alternative schedule 

(Sears or  personal choice)

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3 Tiers of Conviction

•

Due diligence—

“I should assess potential   vaccines just as I would assess a day care 

provider.”

•

Specific concerns from media/internet/  alternate provider 

•

Personal/family/friend experience with  adverse reaction or perceived harm, e.g., 

parent of  child  with ASD;  story of the cat  that died. 

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Rallying—Causes/Advocacy

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One thing we know for sure…Even as reasons for delay/refusal  change somewhat over time, 

as do “solutions”

evidence remains solid that the health care 

provider, you as a pediatrician, are the most important factor in 

a hesitant parent deciding to vaccinate! 

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Q & A Session

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Vaccine Hesitant Parent Concerns: Addressing the Scientific Basis

Dean Blumberg, MD, FAAP

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Vaccine Hesitant Parent Concerns: Addressing the Scientific Basis

Dean A. Blumberg, MD, FAAP

Disclosure–

clinical research grants: Novartis

–

speakers bureau: sanofi pasteur, Merck

Discussion–

“off label” use of FDA approved vaccines

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Vaccine Adverse Event Myths

No credible scientific evidence that vaccines cause:–

autism

–

multiple sclerosis–

diabetes

–

asthma–

inflammatory bowel disease

–

SIDS–

overwhelm immune system

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MMR & Autism

1998: Wakefield Lancet publication–

case series

»

12 children

Biological plausibility: no

10 well done studies–

methods

»

both retrospective & prospective»

ecological & case control

»

millions of children–

results: no association

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Overwhelm Immune System?

Infant immune system–

naïve

–

can respond to thousands of antigens simultaneously

Challenges other than vaccines–

natural environmental exposures

»

strep throat: >50 antigens»

otitis media: >2,000 antigens

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Number of Immunogens in Vaccines1900 1960 1980 2012

Vaccine Immunogens Vaccine Immunogens Vaccine Immunogens Vaccine Immunogens

Smallpox ~200 Smallpox ~200 Diphtheria 1 Diphtheria 1

Diphtheria 1 Tetanus 1 Tetanus 1

Tetanus 1 Pert-WC ~3000 Pert-AC 2-5

Pert-WC ~3000 Polio 15 Polio 15

Polio 15 Measles 10 Measles 10

Mumps 9 Mumps 9

Rubella 5 Rubella 5

Hib 2

Varicella 69

PCV 14

Hepatitis BHepatitis AMCVRVHPVInfluenza*

114

2-74

6-114

Total ~200 Total ~3217 Total ~3041 Total 142-258

Offit et al, Pediatrics 2002;109:124 *Influenza yearly, new strains every year

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Thimerosal Concerns: Neurotoxin?

Thimerosal–

preservative

–

ethylmercury

Toxicity data–

methylmercury

7 well done studies–

methods

»

both retrospective & prospective»

ecological & cohort

»

several 100,000 children–

results: no association

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Thimerosal Content: US Vaccines

Vaccine Trade name Manufacturer Thimerosal

ConcentrationDTaP Tripedia® Sanofi

Pasteur ≤0.00012%Infanrix® GlaxoSmithKline 0Daptacel® Sanofi

Pasteur 0DTaP-HepB-IPV Pediarix® GlaxoSmithKline 0Tdap Adacel® Sanofi

Pasteur 0Boostrix® GlaxoSmithKline 0

Haemophilus influenzae type b conjugate (Hib)

ActHIB® Sanofi

Pasteur 0

PedvaxHIB® Merck & Co, Inc 0Hib/Hepatitis B combo Comvax® Merck & Co, Inc 0Hepatitis B Engerix

B® GlaxoSmithKline 0Recombivax

HB® Merck & Co, Inc 0Hepatitis A/Hepatitis B Twinrix® GlaxoSmithKline <0.0002%Influenza* Various Various Varies

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Aluminum Concerns

Aluminum in vaccines–

adjuvant

–

maximum amount 0.85 mg/dose

Aluminum exposure–

deodorant

–

food»

adults average 7-9 mg/day

•

200 mg in antacids–

breast milk

»

0.04 mg/L–

formula

»

0.225 mg/L

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Aluminum Exposure: 1st 6 Months of Life

0

20

40

60

80

100

120

Breast Milk Formula Soy Formula Vaccines

Source

Mill

igra

ms

Robison et al NIC 2008

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Formaldehyde

Concerns–

high concentrations: DNA damage

»

cellular cancerous changes

Vaccine use–

inactivating agent (influenza, polio, toxins)

–

residual in final product»

maximum amount: <0.1 mg/dose

Human metabolism–

essential intermediate in synthesis of thymidine, purines, amino acids

–

normal blood concentration: 2.5 mg/L

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What is Not in Vaccines

Vaccines do not contain–

human cells or tissue

–

chicken embryos–

monkey kidneys

–

fetal bovine serum–

antifreeze (ethylene glycol)

»

vaccines contain polyethylene glycol (purifies certain vaccines)

•

polyethylene glycol also used in skin creams, toothpaste, laxatives

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29

Cortese

et al Pediatr

2008;121:484

Pertussis Hospitalizations, US

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31

Invasive Pneumococcal Disease Incidence

Rate/100,000 populationCDC: ABC

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Varicella Age-Specific Incidence, US 1990-1994

Rate/100,000 population

CDC: National Health Interview Survey

33Marin et al Pediatrics 2011;128:214

Varicella Mortality Rates, United States

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Haemophilus influenzae type b, 1986Incidence by Age Group

Rate/100,000 populationCDC

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Invasive H. influenzae Type B Disease

Incidence, <5 years -- US

0

20

40

60

80

100

<1987*198719881989

19901991199219931994199519961997

19981999200020012002

Year

Rat

e/10

0,00

0

MMWR 11/98 47:993, 1999;47:38,77, 2002;51:234

conjugatesconjugates

infants

*est.

36parent/guardian deferral or refusel

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Vaccine Hesitant Parent: Scientific Basis Summary

Concerns–

no MMR association with autism

–

vaccines highly purified»

immune system not overwhelmed

»

no thimerosal in virtually all routine pediatric vaccines

»

aluminum vaccine content trivial vs. environment

»

naturally circulating formaldehyde > vaccine content

Vaccine schedule–

protect children when they are most vulnerable

–

delayed vaccines = delayed protection

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Q & A Session

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Vaccine Fears and Controversies: How to Approach Reluctant Parents

Bill Mason, MD, MPH

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Vaccine-Preventable Diseases

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in the CME Activity.

I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations.

I do not intend to discuss unapproved/investigative uses of a commercial product/device in my presentation

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Objectives

Following this presentation attendees will be able to

identify misinformation about vaccines and respond effectively to inform parents.

provide knowledge to parents regarding the tremendous burden that vaccine preventable diseases were in the pre-vaccine era.

distinguish between parents who have unfounded fears or concerns about vaccine from those who have philosophical objection so as to be able to spend the appropriate amount of time with the encounter.

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43

So what happened??!!!?

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Vaccine refusal in schools for PBE*: Washington NEJM 2009;360:1981-1988 *Personal belief exemption

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Vaccine refusal in schools for PBE: California 2009

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Evolution of an immunization program and prominence of vaccine safety

Offit P in Vaccines, Plotkin, Orenstein, Offit eds. Page 1630

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Fear of disease displaced by fear of vaccines

“I took away the fear.”

48

Understanding parents’ fears Pediatrics 2008;122:718

National Immunization Survey 2003-2004 (CDC)

3924 parents responded

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Understanding parents’ fears Pediatrics 2008;122:718

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Understanding parents’ fears Pediatrics 2008;122:718

No doubt indicators 71.7%

Unsure, delayed or both 22.4%(Fencesitters)

Refused 5.9%

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Understanding parents’ fears Amer J Clin Epidemiol 2005;58:1081; J Amer Acad Nurse Pract 2007;19:15

Concern about side effects

Pain and discomfort due to vaccines

Distrust of vaccines; conspiracy theories

Preservatives, heavy metals, long term effects

Infants’ immune systems will be overwhelmed by vaccines

Risk of infection low; diseases are not that bad

Other barriers:

Cost

Transportation

Inconvenience

Parental issues: drug use, lack of knowledge, motivation

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Vaccine-preventable diseases

“Those who cannot remember the past are condemned to repeat it.”

George Santayana

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Vaccine-preventable diseases in US Myers MG, Pineda D 2008

Disease # cases pre-vaccine

Year of vaccine

# cases 2006

Small pox 48,164 Early 1900s 0

Diphtheria 175,885 Mid 1940s 0

Pertussis 142,721 Mid 1940s 15,632

Paralytic Polio 16,316 1955 0

Measles 503,282 1963 55

Congen Rubella 823 1969 1

Invasive Hib 20,000 1985 29

Hepatitis B 26,107 1986 4,713

Varicella 4,000,000 1995 48,445

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Day 4 of rash

55

Poliomyelitis

First described by Michael Underwood in 1789

First outbreak described in U.S. in 1843

21,000 paralytic cases reported in the U. S. in 1952

56

0 20 40 60 80 100

Percent

Asymptomatic Minor non-CNS illnessAseptic menigitis Paralytic

Outcomes of poliovirus infection

57

58

59

Poliomyelitis—United States, 1950-2002

Salk

Sabin

60

Polio Eradication

Last case in United States in 1979

Western Hemisphere certified polio free in 1994

Global eradication goal by ?

61

Measles

Highly contagious viral illness

First described in 7th century

Near universal infection of childhood in prevaccination era

In prevaccine era:

3-4 million cases/year

28,000 hospitalizations

450 deaths

1000 children with chronic disabilities

MMWR 2008;57:203

62

0100200300400500600700800900

1950 1960 1970 1980 1990 2000

Cas

es (t

hous

ands

)

Measles incidence: Reported cases

Measles cases 1950-2000

63

0

5000

10000

15000

20000

25000

30000

1980 1985 1990 1995 2000

Cas

esMeasles—United States, 1980-2002

64

Measles Resurgence— United States, 1989-1991

Cases 55,622

Age group affected Children <5 yrs

Hospitalizations >11,000

Deaths 123

Direct medical costs >$150 million

65

Measles Resurgence: Childrens Hospital Los Angeles, 1989-1991 PIDJ 1993;12:42-48

Cases 440

Mean age 2.1 years

Age group affected 90% children <5 yrs

Hospitalizations 195 (44.3%)

Deaths 3

Direct medical costs $1.7 million

66

Measles Resurgence: Childrens Hospital Los Angeles, 1989-1991 PIDJ 1993;12:42-48

Complications # %

Otitis media 276 63

Diarrhea 197 45

Dehydration 171 39

Pneumonia 160 36

Croup 82 19

Bacteremia 4 1

67

Herd immunity for measles

Vaccination rate needed to prevent measles transmission in a population

90-95%

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Varicella

69

70

71

Varicella: Invasive Group A Streptococcal Infection

72

Varicella: Invasive Group A Streptococcal Infection

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Why get vaccinated?

Because the microbes are still with us

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Why get vaccinated?

Because vaccine-preventable diseases are still here and/or are just a plane ride away

Measles in San Diego (Switzerland)

Measles in Texas, Michigan, & Pennsylvania (Japan)

Mumps (United Kingdom)

Chicken pox (USA)

Pertussis (USA)

Haemophilus influenzae type b (USA)

Hepatitis B (USA)

Meningococcal infections (USA)

Tetanus (USA)

Diphtheria (USA)

75

Why get vaccinated?

Because vaccine-preventable diseases are severe, uncomfortable and they can and do kill.

76

Responding to parents who refuse vaccines Pediatrics 2005;115:1428; NEJM 2009;360:1981

Listen carefully to parents’ concerns

Educate regarding the morbidity from VPD

Inquire regarding specific concerns and address them

Maintain a supportive, non-judgmental relationship-revisit the issue at each appointment

Know when to stop; accept compromise

Have parents sign a refusal waiver (www.cispimmunize.org/pro/pdf/RefusaltoVaccin- ate_2pageform.pdf)

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How to enhance parental confidence in vaccines Offit, et al in Vaccines 5th ed. Plotkin, Orenstein, Offit eds. page 1642

Be respectful and solicit questions

Be empathetic with parent’s concerns

Provide information specific to parent’s fears

Educate parents before the vaccine appointment

Be informed about vaccine issues and misinformation to be able to respond confidently

Strongly recommend vaccines in unambiguous language

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Specific responses to parent type Vaccine 2005;23:2486-93; Pediatrics 2008;122:718

No doubt indicators 71.7%

Lower information needs, less time

Ask questions

Provide information

Unsure 22.4%

Higher information needs, more time

Encourage dialogue and present a balanced view.

Emphasize benefits of vaccination but discuss risks as well.

Refuse 5.9%

Low or no information needs, less time

“Is your decision firm?” If so document or sign refusal waiver.

Discuss consequences of not vaccinating.

Remain open to discussion and provide information as requested.

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What can we do?

Remember the impact VPD had (and can have) on children

Recognize misinformation and correct with facts

Acknowledge parents’ fears and concerns

Provide information on safety and efficacy of vaccination

Use confident, forceful language in speaking with families (based on the evidence)

http://lizditz.typepad.com/i_speak_of_dreams/2008/10/nancy- snyderman.html Google: Matt Lauer and Nancy Snyderman on vaccines

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Main reasons parents who planned to delay or not to get a vaccine for their child changed their minds

Gust et al Pediatrics 2008;122:718

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Questions?

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Please CompleteOnline Evaluation!

The online evaluation is a requirement for those of you seeking CME/CEU credit.

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Resourceswww.aap-ca.org

AAP – CA District IX

www2.aap.org/immunizationAmerican Academy of Pediatrics

Immunization Resources

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Resourceswww.immunize.org

Immunization Action Coalition

www.cdc.gov/vaccines(August is National Immunization Awareness Month)

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www.shotbyshot.orgShot by Shot

Stories of Vaccine Preventable Diseases

Resources

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Thank you for your support and your

participation !