1. Why hesitate? (A public health perspective)
Christine Hahn, MD Idaho Division of Public Health

2. The evidence for a public health benefit of immunization is clear
Greatly reduced rates of diseases
Small risk to the individual receiving vaccination
Overall improved population health
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3. Strategic Advisory Group of Experts (SAGE) on Immunization of the WHO definition of vaccine hesitancy
“Delay in acceptance or refusal of vaccines despite availability of vaccinations services… It is influenced by factors such as complacency, convenience, and confidence.”
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4. Why isn’t everybody fully vaccinated?
“Complacency” →Things seem OK; is a vaccine for this really needed?
“Convenience” →Effort it takes to get vaccination done
“Confidence” →Uncertainty whether a vaccine may actually be more harmful than beneficial; lack of confidence in the recommendation or generally in those giving the recommendation
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5. Complacency
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6. Diseases less common Cases, U.S. 1950 2013 Diphtheria 5796 Tetanus 486
Tetanus
486 26
Pertussis
120,718
28,639
Polio
33,300 1*
Measles
319,124
187
*vaccine-associated
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7. Complacency
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8. Convenience
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9. Convenience 1995: 15 vaccinations protecting against 9 diseases
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10. Uncertainty
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11. Uncertainty
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12. When I hesitate
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13. Public Health Recommendations from the US Preventive Services Taskforce
Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing. All members volunteer their time to serve on the USPSTF, and most are practicing clinicians. Supported by AHRQ to support it
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14. I am “mammography hesitant”
1 in 9 women who live to be at least 85 years of age will develop breast cancer
Mammography detects breast cancer early
US Preventive Services Task Force estimates the benefit of mammography in women aged years to be a 30% reduction in risk of death from breast cancer. For women aged years, the risk of death is decreased by 17%.
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15. Complacency I’m at “low risk” by family history
I’m at “low risk” by lifestyle risk factors
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16. 1/4/2016

17. Convenience
Mammography not done as part of routine health visit; requires special appointment
Can be uncomfortable or even painful for some
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18. Uncertainty Frequent changes to recommendations
Disagreement among various medical societies on best practices
Potential harms
Radiation is scary and does increase risk of some types of cancer
Fear of unnecessary biopsies from a false positive result
Inability to predict which cancers will progress
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19. Uncertainty: Mammography
1979 NIH conference: annual screening for women 50 and older; screening for women in their 40s only at high risk
1980s NCI: routine screening for women in their 40s
1989 Eleven health care organizations: initial baseline mammogram for women age 35 to 39, and every one to two years for women over 40.
1992 ACS drops its recommendation for baseline mammography for women 35 to 39.
1993 NCI drops its recommendation for screening in the 40s
1997 NIH conference: not enough evidence to recommend routine screening for women in their 40s. An institute advisory board recommends mammography in the 40s and every 1-2 years.
1997 ACS: annual mammography for all women over 40, and clinical breast exams close to or, preferably, just before the annual mammogram.
2001 A Danish study suggests that mammography’s value may have been overstated.
2002 Independent panel at NCI decides it can no longer make a recommendation on whether women should be screened. NCI stands by its recommendation: women 40 and older should have screening.
2007 Guidelines issued by the ACP acknowledge that regular mammograms for women in their 40s can reduce the risk of dying from breast cancer by a modest amount but false positives common. Women in their 40s and their doctors periodically should evaluate their risk.
2008 A Norwegian study in Archives of Internal Medicine suggests some invasive breast cancers may go away without treatment, ie, may spontaneously regress.
2009 New guidelines in Annals of Internal Medicine recommend that most women start regular breast cancer screening at age 50, not 40, and that women age 50 to 74 should have mammograms less frequently — every two years, rather than every year.

20. Uncertainty: Mammography
Current recommendations from USPHS Task Force:
mammography should be every other year for women years and starting earlier should be an individual decision; mammography lacks evidence for benefit in women 75 years of age and older.
Current recommendations from American Cancer Society:
Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so.
Women age 45 to 54 should get mammograms every year.
Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening.
Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.
All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. They also should know how their breasts normally look and feel and report any breast changes to a health care provider right away.

21. Uncertainty: mammography
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22. When do YOU hesitate? Screening for colon cancer for all at age 50?
Daily aspirin for men >45 and women >55 who are at increased risk of heart disease or stroke?
Annual flu shot?
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23. What can help overcome hesitancy?
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24. 1/4/2016

25. Education: Wake-up Call
PEDIATRICS April 2014
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26. Effective Messages in Vaccine Promotion: A Randomized Trial
1759 parents age 18 years and older residing in the United States who have children in their household age 17 years or younger
Parents were randomly assigned to:
(1) information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention;
(2) textual information about the dangers of the diseases prevented by MMR from the Vaccine Information Statement;
(3) images of children who have diseases prevented by the MMR vaccine;
(4) a dramatic narrative about an infant who almost died of measles from a Centers for Disease Control and Prevention fact sheet;
or to a control group.
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27. Effective Messages in Vaccine Promotion: A Randomized Trial
None of the 4 interventions increased intent to vaccinate among parents who are the least favorable towards vaccines
Corrective information from the CDC website successfully corrected misperceptions about MMR causing autism but also reduced vaccination intent among parents with least favorable vaccine attitudes
Both the dramatic narrative and images of sick children increased misperceptions of MMR vaccine
The study authors concluded that their findings emphasize the importance of testing health messages for effectiveness before dissemination
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28. Effective Messages in Vaccine Promotion: A Randomized Trial
Health messages must be tested before dissemination to assess their effectiveness, especially among resistant or skeptical populations.
Corrections of misperceptions about controversial issues like vaccines may be counterproductive in some populations.
The best response to false beliefs is not necessarily providing correct information.
Trying to scare parents with emotive stories could paradoxically increase vaccine safety concerns among those who are already hesitant to immunize.
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29. If not information from a third party, then what works?
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30. Thank you!
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