Communicating with parents, providers, and the media

Alan R. Hinman, MD, MPH

October 16-17, 2007

Outline of presentation

• General considerations of vaccine use• Risk assessment, management, and

communication• Parent attitudes, provider practices• Role of the media• What can we do?

Modern vaccines

• Modern vaccines are safe and effective• However, they are neither perfectly safe nor

perfectly effective

• Some persons who receive vaccine will have adverse event

• Some persons who receive vaccine will not be protected

Balancing benefits and risks

• Use of vaccine depends on balance of benefits and risks

• This balance may change over time– For example, OPV/IPV

National Research Council Definitions

• Risk assessment – use of the factual base to define the health effects of exposure of individuals or populations

• Risk management – weighing policy alternatives and selecting appropriate actions

Risk Communication

• Risk has technical and cultural components• Technical – hazard• Cultural – “outrage”

Risk = Hazard + Outrage

Source: Sandman 2002

Outrage FactorsLow High

Voluntary CoercedNatural IndustrialFamiliar ExoticNot memorable MemorableNot dreaded DreadedChronic CatastrophicKnowable UnknowableIndividual control Controlled by othersFair UnfairMorally irrelevant Morally relevantTrustworthy sourcesUntrustworthy sourcesResponsive process Unresponsive process

Features of postmodern society

• Distrust of science• Greater attention to risk• Readiness to refer to the judiciary• Better access to real-time information• Physicians as knowledge managers rather

than knowledge repositories

Source: Muir Gray – Lancet 1999;354:1550-1553

Postmodernism – Public Health

• Scientists must take care not to treat fear and reservation as ignorance and then try to destroy them with a blunt “rational” instrument.

Source: Pattison – BMJ 2001;323:838-840

Maturity

Incidence

Disease

VaccineCoverage

AdverseEvents

Prevaccine IncreasingCoverage

1

Loss ofConfidence

Outbreak

VaccinationsStopped

Eradication

Eradication

2 3 4 5

Resumption of Confidence

Evolution of Immunization Program and Prominence of Vaccine Safety

Parents’ beliefs about immunizations - 1 • Imm one of safest medicines 78%• Imm getting better & better 89%• Imm always proven safe before use 71%• I have access to information 92%• Imm requirements protect my child 84%• Parents should be allowed to send

unimmunized kids to school 14%

Parents’ beliefs about immunizations - 2• Kids get more shots than are good

for them 23%• Immune system could be weakened

by too many immunizations 25%

Source: Gellin et al, Peds 2000;106:1097-1102

Reasons for lack of supportfor immunizations

• Ignorance• Fear• Contraindication• Religion• Philosophy• “Informed” opposition

Unvaccinated vs undervaccinatedSmith. Peds. 2004;114:187-195

• Unvaccinated more likely to be white, have married mother with college degree, live in house with income 75,000, and have parents with concerns about vaccine safety

• Undervaccinated more likely to be black, have unmarried mother without college degree, live in house near poverty level, and live in a central city

Parental concerns and behavior after immunization

Gust. Am J Prev Med 2006;31:32-35

• Parents who sought medical attention for a child due to AEFI compared to those who did not

• Those who sought medical attention more likely to be white, >35, believe that immunizations cause minor side effects, report unwanted yet required immunization, not want a new baby to be fully immunized, report concerns about vaccine safety, believe that immunizations are dangerous, have a child missing 2+ doses of DTP, MMR or hep B

Suspicions about the safety of vaccinesCampion. NEJM 2002;347:1474-1475

“Objective data are not likely to put an end to the controversy. Strongly held beliefs are difficult to change. We live in an era in which the public does not have a high degree of trust in the vaccine manufacturers, the government, or the medical establishment. Consumers have become highly sensitive about safety…

Suspicions about the safety of vaccinesCampion. NEJM 2002;347:1474-1475

Unsubstantiated accusations that a vaccine causes harm can have serious consequences

• Some people avoid vaccination• Costly legal action follows• Manufacturers associate vaccines with

adverse economic effects• Vaccines may be withdrawn from the market• It becomes harder to run vaccination

programs

Vaccine requirements2006-2007 school year

• Diphtheria 50• Tetanus 50• Polio 50• Measles 50• Rubella 50• Mumps 48• Pertussis 48• Hepatitis B 48

• 2d measles 45• Varicella 49• Hepatitis A 6

• Hib (DC) 50• Hib (Head Start)47

Exemptions to immunization requirements

2006-2007 school yearMedical 50 states

Religious 48 states

Philosophical 17 states

Frequency of exemptions2003-2004 school year

Type #rep High State#>1.0%

Med 2.6% IN 4

Rel 3.2% WY 4

Phil 3.6% WA 10

Children entering kindergarten with vaccination personal belief exemptions, 2006

California Dept of Health ServicesImmunization Branch

0 – 49

50 – 99

100 – 199

200 - 1102

Number PBEs

0.00 – 0.99

1.00 – 2.99

3.00 – 4.99

5.00 – 14.37

Percent PBEs

Opposition to immunization - 1

• <1% of entering students have exemptions– 7 states had >1%– Michigan had 2.3%

• 13 outbreaks of measles 1985-1994• Recent outbreaks of pertussis and rubella• 1970s outbreaks of polio• RPEs have 11-52x risk of measles

Opposition to immunization - 2

Pertussis incidence 10-100x higher

in countries where immunization

programs were compromised by

anti-vaccine movements

Source: Gangarosa et al, 1998

Opposition to immunization - 3

11/113 child deaths associated with “religion-motivated medical neglect”

1975-1995 due to VPD

– 7 measles

– 3 diphtheria

– 1 pertussis

Source: Asser and Swan, 1998

Pediatricians’ Communication with Every Dose of DTP/DTaP

• Discuss risks/benefits 53.6%• Distribute VIS 61.2• Document VIS 55.0• Document verbal consent 36.2• Obtain signature 72.4

Source: AAPNews, Feb 2003 p71

Antivaccination Web Sites - 1

• Identified 22 antivaccination web sites• Studied content and design attributes

Source: Wolfe et al JAMA 2002;287:3245-3248

Antivaccination Web Sites - 2

• 100% - vaccines cause idiopathic illness• 95% - vaccines erode immunity• 95% - adverse reactions underreported• 91% - vaccine policy motivated by profit• 81% - vaccines produce temporary imm.• 77% - mandatory vax violate civil liberties• 73% - diseases declined w/o vaccines• 50% - multiple vax increase risk

Types of misinformation found on websites critical of vaccines

• False conclusions from true statements• “Straw man” arguments• Hidden profit motivation• Appeals to emotions• Lies• Appeals to distrust of govt & industry

Source: T Anderson, IAC, 2003

Antivaccination activists on the world wide web

Davies. Arch Dis Child 2002;87:22-25

• Used 7 search engines on “vaccination”and “immunisation or immunization”

• 43% of sites using “vaccination” returned antivaccination sites vs 6% using “immunisation or immunization”

Antivaccination activists on the world wide web

Davies. Arch Dis Child 2002;87:22-25

Rhetorical appeals• Evidence of authority and scientific rigour• Emotive appeals• Evidence of conspiracy, search for truth• Explicit claims

Subtexts in anti-immunization articles

Leask. Aust N Z J Public Health 1998;22:17-26• Cover-up• Excavation of the facts• Unholy alliance for profit• Towards totalitarianism• Us and them• Poisons• Vaccines as the cause of idiopathic ills• Back to natures

Profit motive or altruism?

• “GlaxoSmithKline (GSK) is trying to get the hepatitis A vaccine made mandatory for children entering California schools…

• “…The company has made large campaign contributions, and much of the money has gone to Hispanic legislators, who have introduced a mandatory vaccine bill three times over the past three years.”

Source: Sacramento Bee, July 14, 2002

Profit motive or altruism?

• “Merck & Co. is helping bankroll efforts to pass state laws requiring girls as young as 11 or 12 to receive the drugmaker’s new vaccine against the sexually transmitted cervical cancer virus.”

Source: Associated Press, January 30, 2007

IOM Workshop on risk communication and vaccination

• Risk communication is a dynamic process• Goal should be informed decision-making• There is uncertainty about risk estimates -

honesty about this will contribute to trust

Source: Stoto et al, 1998

Institute of Medicine Report on MMR and Autism - 2001

“…the committee has concluded that the evidence favors rejection of the causal relationship at the population level between MMR vaccine and ASD…its conclusion does not exclude the possibility that MMR vaccine could contribute to ASD in a small number of children…”

Institute of Medicine Report on MMR and Autism - 2004

“The committee concludes that the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism...[and] between thimerosal-containing vaccines and autism...potential biological mechanisms for vaccine-induced autism...are theoretical only.

“...available funding for autism research [should] be channeled to the most promising areas.”

Themes for dealing with doubts

• Carpe diem• Be prepared• For advanced doubters, be very prepared• Appreciate the illogical

Source: Scheifele, 1997

Achieving / Maintaining Communication Credibility

• Respond quickly• Get the facts right, repeat them

consistently• Express empathy and caring, acknowledge

uncertainty• Provide competent spokespersons with

expertise• Provide honest, open responses even if

they are not positive• Follow through, do what we say we will

Multiple media / information sources

• Over 1,500 daily newspapers• Over 15,000 health, medical, and science-

related websites• Hundreds of consumer and professional

publications (e.g., magazines, newsletters)• A multitude of television networks, stations,

and programs• A host of radio networks and stations

Which means. . .• Lots of competition for media, provider, and

public attention• Competition for medical and health

recommendations • High potential for conflicting information and

advice• More is usually not better• Different interpretations are likely

Competing goals and conventions

Public Health• Thoughtful, considered,

and consistent approach to new developments, data, research

• Precisely accurate information and recommendations

• Quickly build (and/or retain) population adoption of a specific recommendation

• Frequent, high visibility stories that promote health and recommendations for safe/healthy living

• Media story = immediate behaviors by many

News Media• Ongoing need for things to be

“new” (new angles, new developments)

• Stories, information, and ideas that highlight a spectrum of healthy, risky, and dangerous things and perspectives

• Be unique / be different• Build/retain an audience• “Essentially” accurate

information – conveyed with interesting and colorful quotes

• Simple and often provocative headlines

Vaccine-related Communications: Challenging Media Conventions

• Length – journalists and editors try to retain the truthfulness of a story while condensing it.

• Media create and present “stories”– Good stories require conflict – and conflict

usually requires “victims,” “villians” and “heroes”

– Colorful quotes– “Balance” (e.g., stories generally need more

than one point of view)– Nuance and context are often lost in the

process• Headlines must grab attention

Things to Keep in Mind

• Reporters are not “court” reporters – They are not transcribing your comments– They paraphrase and can alter context– “Translation” and interpretation are viewed

as key roles• Reporters are not the only people involved in

the final story and its presentation– Editors play significant roles– Reporters don’t write the headlines

• Nuances and fine distinctions rarely translate

Mixed messages can easily arise. . .

• “It’s (really) important you get an influenza vaccination” vs. “You can wait until (December, January, February, etc.)”

• “Influenza is a potentially serious disease/illness” vs. “For the vast majority of people, influenza is an unpleasant but manageable illness.”

• “Everyone benefits from an influenza vaccination” vs. “People in the following groups (really) benefit from an influenza vaccination.”

• “It’s important you get vaccinated” vs. “It’s important you get your vaccination from (______________)”

Keys to Effective (Risk) Communication

• Credibility • Trust / Honesty• Mutual respect • Commitment • Expertise (including good quality

information)• Empathy• Recognition that individual decisions may

be based more on values than on evidence

Factors affecting vaccine acceptance(Ball, Peds 1998;101:453-458)

• Compression• Omission bias vs commission bias• Ambiguity aversion• Voluntary, controllable risks• Natural risks• Frightening or memorable risks• Availability• Freeloading• Bandwagoning• Altruism

6 common misconceptions about vaccination

• Diseases had already begun to disappear• Majority of people who get disease have been

vaccinated• “Hot lots” of vaccine have been associated

with more adverse events• Vaccines cause harmful side effects,

illnesses, and even death• VPD have been virtually eliminated from US• Multiple vaccinations at same time increase

risk of harmful side effects and can overload the immune system

Addressing parents’ concerns about childhood immunization:

A tutorial for PCP

• Levi. Peds 2007;120:18-26• CD-ROM based 45 minute tutorial• Significantly improved residents’ general

knowledge, knowledge of adverse events, and attitudes regarding immunization

• Will become available soon

Components of effective risk communication

Ball. Peds 1998;101:453-458• Communicate existing knowledge• Recognize factors influencing parental risk

perception• Acknowledge potential risk communication

pitfalls• Engage parents appropriately – decision-

making partnership with physician

AAP and parental refusal

• 79% of pediatricians have had >1 instances of parents refusing to allow child to be vaccinated

• ~10% of pediatricians report >10% of parents avoiding vaccines because of safety concerns

Responding to parental refusals of immunization of children

Peds. 1005:115:14281431

• 3 distinct issues– Do parents who withhold immunizations

risk harming children sufficiently that this is actionable medical neglect that should be reported to child protective services

– Do parental decisions put other individuals at risk of harm sufficient to justify public health intervention

– How should pediatrician respond to parents who refuse immunizations for their children

Responding to parental refusals of immunization of children

Peds. 1005:115:14281431

• Listen carefully and respectfully to parent’s concerns• Share honestly what is and is not known about risks and

benefits of the vaccine• Assist parents in understanding that risks of immunization

should be considered in comparison of risk of not being immunized

• Discuss concerns about specific vaccines• Discuss concerns about multiple shots• Explore whether cost is a reason• Respect (and document?) continued refusal• Generally avoid discharging patients because of refusal

Summary

• Vaccines have had a major impact on disease incidence (>95% reduction)

• Immunization coverage at record high• Extensive process for risk assessment and

risk management• Major shortcoming is in risk communication• Providers need to listen and communicate

effectively

Talk with people,not to them or at them