1. Robert M Jacobson, MD, FAAP Professor of Pediatrics, Mayo Clinic President, SEMIC Med Dir, Mayo’s Primary Care Immun Program President, MN Chap Amer Acad of Pediatrics Working with Vaccine Hesitant Parents using the C.A.S.E. Approach

2. Disclosures Potential conflicts – Safety Review Committee Male HPV4 Gardasil® vaccine (Merck) – Data and Safety Monitoring Board Adult and infant PCV15 (Merck) No off-label use discussion

3. Disclosures Potential conflicts – Jacobson v Massachusetts – Reverend Henning Jacobson – Martin Bror Johan Jacobson – Robert Bror Jacobson

4. Learning Objectives Relate a new approach to vaccine hesitancy Identify each of its 4 components Describe how it works in 3 common scenarios

5. The State of Vaccination The anti-vaccine movement is thriving – Successful vaccination makes its value invisible – Media seeks to portray controversy, “both sides” – Americans culturally opposed to “social health” Vaccine hesitancy is a major issue – Not just among exempters and delayers – Even 25 to 30% of those up-to-date Both vaccine provider and parent struggle

6. The Vaccine Provider in the Office Has little time for discussion Suffers a sense of rejection as wise advisor Feels sense of futility Recognizes problem of health illiteracy

7. The Parent in the Office Would like to be heard Wishes to be respected Seeks credible information Wants control; wants to make the decision

8. The Back Fire Effect Nyhan et al 2014 1759 parents 18 years and older Two waves of online messaging Randomized 5 different interventions – Info explaining the lack of evidence re autism – Info re dangers of diseases prevented by MMR – Images of children w/diseases prevented by MMR – Dramatic narrative re infant almost died of measles – Control group

9. The Back Fire Effect Results – None of 4 interventions increased intent to vaccinate – Info re autism improved expressed knowledge but decreased intent to vaccinate – Images and narrative worsened fears re autism

10. Clinician Recommendation Matters Many studies across many vaccines and ages – Gnanasekaran 2006 – Nowalk 2007 – Guerry et al 2011 – Brewer et al 2011 – Ylitalo et al 2013 – Darden et al 2013 – Jacobson and Darden 2014 Clinician recommendations increase rates

11. Hey, lady! Where do you want this health care delivered?

12. Information Transfer Not Enough Hey, lady! Where do you want this health care delivered?

14. Rhetoric

15. Logos

16. Rhetoric Logos Ethos

17. Rhetoric Logos Pathos Ethos

18. Persuasion Information Passion Standing

20. The C.A.S.E. for Vaccines A model for talking to vaccine-hesitant parents A mnemonic to organize a rapid, useful response Created by Alison Tepper Singer – Formerly, NBC and CNBC television producer – Mother of an autistic child – Quit Autism Speaks over its anti-vaccination stance – Founding CEO of Autism Science Foundation – Strong advocate of science and routine vaccination

21. The Case for C.A.S.E. Provides more than just information Has historical roots in Aristotelian rhetoric Lacks published studies of its efficacy Nonetheless has face validity Lacks competing alternatives Preserves the relationship

22. The C.A.S.E. Acronym Corroborate About Me Science Explain/Advise

23. The C.A.S.E. Approach Corroborate: – Acknowledge the person’ concern – Find some point on which you can agree – Set the tone for a respectful, successful talk About Me: – Describe what you have done to build your knowledge base and expertise Science: – Relate what the science says Explain/Advise: – Explain your advice to patient, based on the science

24. A Hesitant Parent We want to pass on the MMR vaccine today. The others are fine.

25. C for Corroborate Please tell me why you want to pass on the MMR vaccine.

26. The Parent’s Specific Concern I’m worried that it might cause autism. There’s just too much in the news about it.

27. More Corroboration If the MMR vaccine caused autism, I wouldn’t want your child to get it either. Just like you, I want to do whatever I can do to keep your child healthy.

28. A for About Me I have been studying this claim for many years now and have read the studies that tested whether the MMR vaccine causes autism. I’ve also been reading the studies about the autism itself.

29. S for Science Dozens of very large, well-done studies have shown that the MMR vaccine does not cause autism.

30. More Science In fact, the studies about autism show that children who are going to get autism show the signs of autism long before they receive the MMR vaccine.

31. More Science On the other hand, the MMR vaccine prevents measles disease, and I have seen how serious measles disease can be. 1 in 3 children have been so sick they had to be hospitalized. Some die of measles.

32. E for Explain We both want your child healthy. Your passing on the MMR will not protect your child from autism, but it will leave your child at risk for diseases that can result in hospitalization or worse. As your child’s doctor, I urge you to have your child get the MMR vaccine.

33. Another Hesitant Parent It’s just too many shots at once. I just want to spread them out and give them one at a time.

34. C for Corroborate We do give more injections now in the first few visits. What specifically worries you about that?

35. More Specifics Won’t it overload her immune system? How do we know it’s really safe?

36. More Corroboration You are not the first parent to ask that question. My own spouse asked me about that at our first baby’s two-month check-up.

37. A for About Me So I read through the recommendations carefully and the discussions among experts about the safety of giving all these vaccines together.

38. S for Science Although kids get more shots today, they actually receive fewer antigens than when they got fewer shots, because technology has enabled us to make vaccines that have only the part of the cell that induces immune response.

39. More on Science Plus, the immunological challenge from a vaccine is nothing compared to what kids fight off every day. An ear infection is a bigger immunological challenge.

40. E for Explain/Advise We want all the kids in our practice to be immunized so that they have the greatest chance for a long, healthy life. I made sure my own children got all the vaccines recommended on time.

41. A Hesitant Mother-to-Be I don’t want a Tdap, I just had one after I had my baby two years ago. It just doesn’t seem safe.

42. C for Corroborate I too wondered about the frequency of getting Tdap during every pregnancy. We used to say only one Tdap ever.

43. A For About Me So, I went to the recommendations that were just published to better understand the reasoning and the data a Tdap for each pregnancy.

44. S For Science Pertussis can be most severe in infant who have started their vaccination. The majority of deaths occur in infants less than three months old.

45. More on Science I learned that the recommendation was made to take advantage of the mother’s ability to pass on pertussis protection to the baby so the baby is protected until they are old enough to get vaccinated.

46. More on Science Because the level of protective antibodies declines after the first year of vaccination, it won’t protect babies from future pregnancies.

47. More on Science Meanwhile studies show the Tdap is safe to pregnant mothers and their fetuses. That’s why they’ve made this recommendation.

48. More on Science So far what experts have observed is swelling and redness at the injection site. It won’t cause you harm and it just may save your baby’s life.

49. E for Explain/Advise Protecting your baby against pertussis in the first couple months is so important that I recommend that you get the Tdap today.

50. Other Forms of Corroborate I’ve heard that too I first thought that as well Lots of parents wonder about that We both want your child healthy, safe, and free of disease

51. Other Forms of About Me This is one of the most important things I do I’ve been studying this topic for years I’ve dedicated my life to this work I lose money on vaccines but I don’t regret it

52. Other Forms of Science Let me tell you a story about a patient of mine… No vaccine is 100% safe but studies show… I asked a leading expert the same question…

53. Other Forms of Explain/Advise That’s why I got the vaccine myself That’s why I made sure my baby got this vaccine If I had children, I’d get them this vaccine If I were in your shoes, I’d choose to vaccinate I feel more strongly about this than I do about antibiotics for ear infections

54. C.A.S.E. Not just information Not scare tactics But your advice You have more than the science You have your connection with the parent You have your standing with the parent You have the passion you hold for your advice

55. The C.A.S.E. Approach Corroborate: – Connect emotionally with the parent – About Me: – Buttress your professional standing with the parent Science: – Summarize the science Explain/Advise: – Passionately advise given your status or standing and the science

56. Practice Pair up in twos Have one play the role of a hesitating parent Have one play the role of vaccine provider Work through all four steps of C.A.S.E. – Corroborate – About Me – Science – Explain/Advise

57. Summary Relate a new approach to vaccine hesitancy – Passionately advise using science and standing Identify each of the 4 components of C.A.S.E. – Corroborate – About Me – Science – Explain/Advise Describe how it works in 3 common scenarios