Patricia Stinchfield, RN, MS, CPNP

Director, Infectious Disease/Immunology/Infection Control

Advisory Committee on Immunization Practices, voting member representing National Association of Pediatric Nurse

Practitioners (NAPNAP)

“Effectively Addressing Parents’ Concerns about Immunizations”

Centers for Disease Control and Prevention

Vaccine Safety Netconference

June 12, 2008

Experience and Values Drive Risk Communications

My experience: 30 years as a pediatric RN, 21 of those as a Pediatric Nurse Practitioner in Infectious Disease/Immunology

Cared for numerous children with vaccine preventable diseases including pertussis, measles, influenza, severe varicella and rotavirus and pneumococcal, Hib and meningococcal meningitis

Parents and many providers today have never seen these diseases so the benefit of vaccines is invisible

When you care for the sickest of the sick, the bias is strong in favor of vaccination.

Vaccine Debates: Impact on Parents

National vaccine debates cause great vaccine communication challenges at the patient care level

Parents can be confused, misinformed or fearful of vaccines because of a story they read/see.

The vaccine communication challenges are many

The perspective is often skewed

(1 mom interviewed on news who vaccinates represents 98% of parents, whereas the other mom choosing not to vaccinate interviewed represents 2% of parents)

Provider Impact

40% of providers surveyed did not mention vaccine risks with patients (Davis)

Research supports that physicians say little to parents about immunizations (Ball et al)

Parents want info from providers (Gellin) Nurses reported the most education in

risk:benefit communication (Davis, et al) but may not always have the responsibility to educate

With recent media attention to the topic, more and more providers are spending considerably more time discussing immunization concerns with parents

“An Infant’s Immune System is Too Weak for Vaccines?”

Take a moment early on and briefly describe the power of the human immune system

T and B lymphocytes are abundant in a “lock and key” ability to deal with antigens individually; therefore no “immune system overload”

The ocean analogy Even premature babies have the immune

capacity to respond to inactivated vaccines

With few exceptions, when they are 60 days old, even in an NICU, babies are started on their immunization series and can make protective level antibodies

“So Many So Soon,So Many at One Visit”

Vaccinate by the recommended schedule that has been thoroughly reviewed by experts, most of whom are also parents

There is no physiologic reason to design an alternative immunization schedule

There is no biological rationale for splitting up a dose

To choose to delay is to choose to take a risk

If avoidance of harm is the goal, to prolong prevention is to delay protection

Choosing to not vaccinate not only potentially endangers this baby, but others as well.

“Is Thimerosal the Problem?”

The preservative thimerosal has been removed from vaccines with the exception of multi-dose influenza

Multi-dose vials of influenza vaccine contain thimerosal as a preservative

This requires time for conversation in the clinics about thimerosal, even in mass influenza vaccination settings

Danish cases of autism rose substantially after thimerosal was removed in 1992 (AJPM 8/2003)

Theoretical/unproven risk with thimerosal vs. real/considerable risk with disease

Education on the lack of scientific support for thimerosal as a causative agent of autism is as necessary as ever

“Do Vaccines Cause Autism?”

The Institute of Medicine has reported that there is no correlation between thimerosal content in vaccines and autism (NEJM 9/07)

We do not yet know the cause of autism and resources would be best spent understanding this better

Epidemiological studies in different parts of the world have shown no relationship vaccines and autism (Danish study of 500,000 children over 7 years found no association. NEJM 2002)

Vaccine Safety Datalink did not show a relationship between vaccines and autism or other neurodevelopmental disorders (Pediatrics, 11/03)

Temporal association between things is not the same as a causal association

Communication Challenges

Time

Prevention

Complicated science

Disease versus vaccine

Emotions (fear, anxiety) can be driving conversation

Communication Challenges

Languages Perceptions Mind made up mentalities Information resource

challenges leads to misinformation

What Strategies Can Reduce Myths and Misperceptions?

Listen. What is the root of the misunderstanding? Fear? Knowledge deficit? Attitude? Experience? Emotions? Beliefs?

“Balanced” media—is it even possible?

Modeling: Vaccinate Health care Professionals

Storytelling: Sharing real experiences

Wednesday, January 31, 2007

Television news airs photos a family has shared of their 8 year old son “Lucio” who died of Influenza A.

His parents’ hope is to alert parents in order to prevent other children from dying.

Droves of parents called providers concerned asking for influenza vaccine

Telling the real stories makes a difference

Reasons Parents Give Not to Immunize

Medical

– Contraindications

– Precautions

Safety

-Side effects

Philosophical– Individual rights

– Alternative health

Religious– Not health care

consumer

– Human or animal tissue in vaccines

– “Good health is achieved through seeking God”

What is Safe?

SAFE = No Harm from the vaccine?

No vaccine is 100% safe SAFE = No Harm from the disease?

No vaccine is 100% effective

Have we communicated realistic expectations?

Communicate that the safety and effectiveness of receiving vaccines is far less risky than being un-immunized

To do nothing is to take a risk

Practical Thoughts on Reducing Challenges

Establish Rapport-trust is vital

Determine understanding-what have their experiences been?

Break down emotional barriers

Engage in 2 way conversation

Give personal provider experience with vaccine safety issues

Practical Thoughts continued

Encourage questions Give perspective & real life

examples Provide supporting

information Focus: Keep control without

being controlling

Enhancing Vaccine Communication

Recognize the challenges Meet them where they are Share the goal of informed decision-

making in partnership Engage in a dialogue with trust and

open understanding Be evidence based and as definitive

as the science allows Individualize the message and

methods of communication.

Enhancing Vaccine Communication

Use current information, VIS Communicate clearly in plain

language with visual aids Use analogies Keep it interactive Use videos, group teaching Provide reliable websites Parent-to-parent sessions Taped phone messages

Use the Five C’s of Effective Communication

Chemistry Clarity Consistency Credibility Caring

Simple is Better

Keep it simple– A one sentence description of the disease– A word about its prevalence/dangers in

your community and the world– Describe the vaccine benefits– Describe the vaccine risks and the risks of

not immunizing– Advise about normal, local responses– Inform about what to do in the event of a

severe adverse reaction– Emphasize the return visits based on the

recommended schedule

Emphasize Ongoing Safety Monitoring

Many ways that vaccines are monitored on an ongoing basis:

Vaccine Safety Datalink (large HMO data analysis)

VAERS (Vaccine Adverse Event Reporting System through the CDC & FDA, relies on providers)

CISA centers (6 centers for immunization safety assessments)

Ongoing post-marketing surveillance by manufacturers

Summary

Many vaccine communication challenges exist in the practice setting today

Determine the origin of concerns Address concerns with effective

risk:benefit communication strategies Underscore safety is top priority for us all Safety monitoring is ongoing Utilize creative strategies to communicate

efficiently such as group classes, taped phone messages, reliable resources brochures, parent-to-parent sessions

Keep communication clear, compassionate yet confident