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Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007.

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Presentation on theme: "Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007."— Presentation transcript:

1 Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007

2 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?

3 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

4 Balancing benefits and risks Use of vaccine depends on balance of benefits and risks This balance may change over time –For example, OPV/IPV

5 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

6 Risk Communication Risk has technical and cultural components Technical – hazard Cultural – outrage Risk = Hazard + Outrage Source: Sandman 2002

7 Outrage Factors Low High VoluntaryCoerced NaturalIndustrial FamiliarExotic Not memorableMemorable Not dreadedDreaded ChronicCatastrophic KnowableUnknowable Individual controlControlled by others FairUnfair Morally irrelevantMorally relevant Trustworthy sourcesUntrustworthy sources Responsive processUnresponsive process

8 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

9 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

10 Evolution of Immunization Program and Prominence of Vaccine Safety

11 Parents beliefs about immunizations - 1 Imm one of safest medicines78% Imm getting better & better89% Imm always proven safe before use 71% I have access to information92% Imm requirements protect my child 84% Parents should be allowed to send unimmunized kids to school14%

12 Parents beliefs about immunizations - 2 Kids get more shots than are good for them23% Immune system could be weakened by too many immunizations25% Source: Gellin et al, Peds 2000;106:1097-1102

13 Reasons for lack of support for immunizations Ignorance Fear Contraindication Religion Philosophy Informed opposition

14 Unvaccinated vs undervaccinated Smith. 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

15 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

16 Suspicions about the safety of vaccines Campion. 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…

17 Suspicions about the safety of vaccines Campion. 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


19 Vaccine requirements 2006-2007 school year Diphtheria50 Tetanus50 Polio50 Measles50 Rubella50 Mumps48 Pertussis48 Hepatitis B48 2d measles 45 Varicella 49 Hepatitis A 6 Hib (DC) 50 Hib (Head Start)47

20 Exemptions to immunization requirements 2006-2007 school year Medical50 states Religious48 states Philosophical17 states

21 Frequency of exemptions 2003-2004 school year Type#repHighState#>1.0% Med 2.6% IN 4 Rel 3.2% WY 4 Phil3.6% WA 10

22 Children entering kindergarten with vaccination personal belief exemptions, 2006 California Dept of Health Services Immunization 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

23 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

24 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

25 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



28 Pediatricians Communication with Every Dose of DTP/DTaP Discuss risks/benefits53.6% Distribute VIS61.2 Document VIS55.0 Document verbal consent36.2 Obtain signature72.4 Source: AAPNews, Feb 2003 p71















43 Antivaccination Web Sites - 1 Identified 22 antivaccination web sites Studied content and design attributes Source: Wolfe et al JAMA 2002;287:3245-3248

44 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

45 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

46 Antivaccination activists on the world wide web Davies. Arch Dis Child 2002;87:22-25 Used 7 search engines on vaccinationand immunisation or immunization 43% of sites using vaccination returned antivaccination sites vs 6% using immunisation or immunization

47 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

48 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

49 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

50 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 drugmakers new vaccine against the sexually transmitted cervical cancer virus. Source: Associated Press, January 30, 2007

51 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

52 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…

53 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.

54 Themes for dealing with doubts Carpe diem Be prepared For advanced doubters, be very prepared Appreciate the illogical Source: Scheifele, 1997

55 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

56 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

57 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

58 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

59 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

60 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 dont write the headlines Nuances and fine distinctions rarely translate

61 Mixed messages can easily arise... Its (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. Its important you get vaccinated vs. Its important you get your vaccination from (______________)

62 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

63 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

64 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

65 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

66 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

67 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

68 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

69 Responding to parental refusals of immunization of children Peds. 1005:115:14281431 Listen carefully and respectfully to parents 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


71 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

72 Talk with people, not to them or at them

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