Time-Efficient Skills to Address Vaccine-Hesitant Parents: Focus Group Results and Best Practices

Transcription

1 Time-Efficient Skills to Address Vaccine-Hesitant Parents: Focus Group Results and Best Practices 1

2 Is there any way to put a screen shot in here to help people know where / how they can ask a question? 2

3 Objectives At the conclusion of the webinar, participants will be able to: Recognize three factors influencing vaccine safety concerns Identify two key parent perspectives on vaccine messaging Create effective fact based messages to use in practice and media settings. 3

4 Setting the Stage for Good Communication: Parental Concerns About Vaccines Kris Calvin, MPH CEO, AAP- CA 4

5 A Long History Concerns about vaccines have been around since they first were developed. Ben Franklin in the 18 th century was a fervent anti vaccine proponent until his 4 yr old son died of smallpox, after which he said: I long regretted bitterly, and still regret that I had not given it to him by innoculation Healy & Pickering Pediatrics Online

6 2009 Pediatrician Focus Groups by AAP CA (CDC funded) Perceived Parental Concerns Autism Thimerosal (mercury) Aluminum Pain from shots, minor reactions Number of shots Newness of vaccines/not properly tested (HPV) Belief that risk of disease is near zero 6

7 2012 Parent Focus Groups (First 5 OC funded) Call themselves vaccine educated Not anti vaccine parents themselves seek out vaccinations Many do not name autism as concern (although may be implicit); may be insulted if MD thinks they believe in this link. 7

8 More Mama Bear/Papa Bear NOT concerned about public health/responsibility is only to protect their own child. Compare their child s rosy cheek unvaccinated health (I never have to see a doctor) with those they perceive as often sick that have been vaccinated. 8

9 2012 groups (cont) Concern over developing immune system # of shots/antigens, desire for green shots (no formaldehyde,etc) Belief that getting a disease naturally is better, creates stronger immunity Belief they understand science better then scientists, since they are unbiased, not influenced by $$ 9

10 Ongoing across time Still core problem that they have not seen and do not fear vaccine preventable diseases Subset of chiropractors, alternative providers highly influential Selected shots concern them MMR,varicella HPV, Hep B at birth Loving parents some fearful, some know itall, but by and large all concerned most with their child s welfare. 10

11 Their Solution? * Refuse/delay/alternative schedule (Sears or personal choice) 11

12 3 Tiers of Conviction Due diligence I should assess potential vaccines just as I would assess a day care provider. Specific concerns from media/internet/ alternate provider Personal/family/friend experience with adverse reaction or perceived harm, e.g., parent of child with ASD; story of the cat that died. 12

13 Rallying Causes/Advocacy 13

14 One thing we know for sure Even as reasons for delay/refusal change somewhat over time, as do solutions evidence remains solid that the health care provider, you as a pediatrician, are the most important factor in a hesitant parent deciding to vaccinate! 14

15 Q & A Session 15

16 Vaccine Hesitant Parent Concerns: Addressing the Scientific Basis Dean Blumberg, MD, FAAP 16

17 Vaccine Hesitant Parent Concerns: Addressing the Scientific Basis Dean A. Blumberg, MD, FAAP Disclosure clinical research grants: Novartis speakers bureau: sanofi pasteur, Merck Discussion off label use of FDA approved vaccines 17

18 Vaccine Adverse Event Myths No credible scientific evidence that vaccines cause: autism multiple sclerosis diabetes asthma inflammatory bowel disease SIDS overwhelm immune system 18

19 MMR & Autism 1998: Wakefield Lancet publication case series» 12 children Biological plausibility: no 10 well done studies methods» both retrospective & prospective» ecological & case control» millions of children results: no association 19

20 Overwhelm Immune System? Infant immune system naïve can respond to thousands of antigens simultaneously Challenges other than vaccines natural environmental exposures» strep throat: >50 antigens» otitis media: >2,000 antigens 20

21 Number of Immunogens in Vaccines Vaccine Immunogens Vaccine Immunogens Vaccine Immunogens Vaccine Immunogens Smallpox ~200 Smallpox ~200 Diphtheria 1 Diphtheria 1 Diphtheria 1 Tetanus 1 Tetanus 1 Tetanus 1 Pert-WC ~3000 Pert-AC 2-5 Pert-WC ~3000 Polio 15 Polio 15 Polio 15 Measles 10 Measles 10 Mumps 9 Mumps 9 Rubella 5 Rubella 5 Hib 2 Varicella 69 PCV 14 Hepatitis B Hepatitis A MCV RV HPV Influenza* Total ~200 Total ~3217 Total ~3041 Total Offit et al, Pediatrics 2002;109:124 *Influenza yearly, new strains every year

22 Thimerosal Concerns: Neurotoxin? Thimerosal preservative ethylmercury Toxicity data methylmercury 7 well done studies methods» both retrospective & prospective» ecological & cohort» several 100,000 children results: no association 22

23 Thimerosal Content: US Vaccines Vaccine Trade name Manufacturer Thimerosal Concentration DTaP Tripedia Sanofi Pasteur % Infanrix GlaxoSmithKline 0 Daptacel Sanofi Pasteur 0 DTaP-HepB-IPV Pediarix GlaxoSmithKline 0 Tdap Adacel Sanofi Pasteur 0 Boostrix GlaxoSmithKline 0 Haemophilus ActHIB Sanofi Pasteur 0 influenzae type b conjugate (Hib) PedvaxHIB Merck & Co, Inc 0 Hib/Hepatitis B combo Comvax Merck & Co, Inc 0 Hepatitis B Engerix B GlaxoSmithKline 0 Recombivax HB Merck & Co, Inc 0 Hepatitis A/Hepatitis B Twinrix GlaxoSmithKline <0.0002% 23 Influenza* Various Various Varies

24 Aluminum Concerns Aluminum in vaccines adjuvant maximum amount 0.85 mg/dose Aluminum exposure deodorant food» adults average 7-9 mg/day 200 mg in antacids breast milk» 0.04 mg/l formula» mg/l 24

25 Aluminum Exposure: 1 st 6 Months of Life Milligrams Breast Milk Formula Soy Formula Vaccines Source Robison et al NIC

26 Formaldehyde Concerns high concentrations: DNA damage» cellular cancerous changes Vaccine use inactivating agent (influenza, polio, toxins) residual in final product» maximum amount: <0.1 mg/dose Human metabolism essential intermediate in synthesis of thymidine, purines, amino acids normal blood concentration: 2.5 mg/l 26

27 What is Not in Vaccines Vaccines do not contain human cells or tissue chicken embryos monkey kidneys fetal bovine serum antifreeze (ethylene glycol)» vaccines contain polyethylene glycol (purifies certain vaccines) polyethylene glycol also used in skin creams, toothpaste, laxatives 27

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29 Pertussis Hospitalizations, US Cortese et al Pediatr 2008;121:484 29

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31 Invasive Pneumococcal Disease Incidence Rate/100,000 population CDC: ABC 31

32 Varicella Age-Specific Incidence, US Rate/100,000 population CDC: National Health Interview Survey 32

33 Varicella Mortality Rates, United States Marin et al Pediatrics ;128:214

34 Haemophilus influenzae type b, 1986 Incidence by Age Group Rate/100,000 population CDC 34

35 Invasive H. influenzae Type B Disease Incidence, <5 years -- US conjugates infants conjugates Rate/100, <1987* Year MMWR 11/98 47:993, 1999;47:38,77, 2002;51:234 *est. 35

36 parent/guardian deferral 36 or refusel

37 Vaccine Hesitant Parent: Scientific Basis Summary Concerns no MMR association with autism vaccines highly purified» immune system not overwhelmed» no thimerosal in virtually all routine pediatric vaccines» aluminum vaccine content trivial vs. environment» naturally circulating formaldehyde > vaccine content Vaccine schedule protect children when they are most vulnerable delayed vaccines = delayed protection 37

38 Q & A Session 38

39 Vaccine Fears and Controversies: How to Approach Reluctant Parents Bill Mason, MD, MPH 39

40 Vaccine-Preventable Diseases I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in the CME Activity. I acknowledge that today s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations. I do not intend to discuss unapproved/investigative uses of a commercial product/device in my presentation 40

41 Objectives Following this presentation attendees will be able to identify misinformation about vaccines and respond effectively to inform parents. provide knowledge to parents regarding the tremendous burden that vaccine preventable diseases were in the pre-vaccine era. distinguish between parents who have unfounded fears or concerns about vaccine from those who have philosophical objection so as to be able to spend the appropriate amount of time with the encounter. 41

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43 So what happened??!!!? 43

44 Vaccine refusal in schools for PBE*: Washington NEJM 2009;360: *Personal belief exemption 44

45 Vaccine refusal in schools for PBE: California

46 Evolution of an immunization program and prominence of vaccine safety Offit P in Vaccines, Plotkin, Orenstein, Offit eds. Page

47 Fear of disease displaced by fear of vaccines I took away the fear. 47

48 Understanding parents fears Pediatrics 2008;122:718 National Immunization Survey (CDC) 3924 parents responded 48

49 Understanding parents fears Pediatrics 2008;122:718 49

50 Understanding parents fears Pediatrics 2008;122:718 No doubt indicators 71.7% Unsure, delayed or both 22.4% (Fencesitters) Refused 5.9% 50

51 Understanding parents fears Amer J Clin Epidemiol 2005;58:1081; J Amer Acad Nurse Pract 2007;19:15 Concern about side effects Pain and discomfort due to vaccines Distrust of vaccines; conspiracy theories Preservatives, heavy metals, long term effects Infants immune systems will be overwhelmed by vaccines Risk of infection low; diseases are not that bad Other barriers: Cost Transportation Inconvenience Parental issues: drug use, lack of knowledge, motivation 51

52 Vaccine-preventable diseases Those who cannot remember the past are condemned to repeat it. George Santayana 52

53 Vaccine-preventable diseases in US Myers MG, Pineda D 2008 Disease # cases pre-vaccine Year of vaccine # cases 2006 Small pox 48,164 Early 1900s 0 Diphtheria 175,885 Mid 1940s 0 Pertussis 142,721 Mid 1940s 15,632 Paralytic Polio 16, Measles 503, Congen Rubella Invasive Hib 20, Hepatitis B 26, ,713 Varicella 4,000, ,445 53

54 Day 4 of rash 54

55 Poliomyelitis First described by Michael Underwood in 1789 First outbreak described in U.S. in ,000 paralytic cases reported in the U. S. in

56 Outcomes of poliovirus infection Asymptomatic Aseptic menigitis Minor non-cns illness Paralytic Percent 56

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59 Poliomyelitis United States, Salk Sabin 59

60 Polio Eradication Last case in United States in 1979 Western Hemisphere certified polio free in 1994 Global eradication goal by? 60

61 Measles Highly contagious viral illness First described in 7th century Near universal infection of childhood in prevaccination era In prevaccine era: 3-4 million cases/year 28,000 hospitalizations 450 deaths 1000 children with chronic disabilities MMWR 2008;57:203 61

62 Measles incidence: Reported cases Measles cases Cases (thousands)

63 Measles United States, Cases

64 Measles Resurgence United States, Cases 55,622 Age group affected Children <5 yrs Hospitalizations >11,000 Deaths 123 Direct medical costs >$150 million 64

65 Measles Resurgence: Childrens Hospital Los Angeles, PIDJ 1993;12:42-48 Cases 440 Mean age 2.1 years Age group affected 90% children <5 yrs Hospitalizations 195 (44.3%) Deaths 3 Direct medical costs $1.7 million 65

66 Measles Resurgence: Childrens Hospital Los Angeles, PIDJ 1993;12:42-48 Complications # % Otitis media Diarrhea Dehydration Pneumonia Croup Bacteremia

67 Herd immunity for measles Vaccination rate needed to prevent measles transmission in a population 90-95% 67

68 Varicella 68

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71 Varicella: Invasive Group A Streptococcal Infection 71

72 Varicella: Invasive Group A Streptococcal Infection 72

73 Why get vaccinated? Because the microbes are still with us 73

74 Why get vaccinated? Because vaccine-preventable diseases are still here and/or are just a plane ride away Measles in San Diego (Switzerland) Measles in Texas, Michigan, & Pennsylvania (Japan) Mumps (United Kingdom) Chicken pox (USA) Pertussis (USA) Haemophilus influenzae type b (USA) Hepatitis B (USA) Meningococcal infections (USA) Tetanus (USA) Diphtheria (USA) 74

75 Why get vaccinated? Because vaccine-preventable diseases are severe, uncomfortable and they can and do kill. 75

76 Responding to parents who refuse vaccines Pediatrics 2005;115:1428; NEJM 2009;360:1981 Listen carefully to parents concerns Educate regarding the morbidity from VPD Inquire regarding specific concerns and address them Maintain a supportive, non-judgmental relationship-revisit the issue at each appointment Know when to stop; accept compromise Have parents sign a refusal waiver ( 76

77 How to enhance parental confidence in vaccines Offit, et al in Vaccines 5 th ed. Plotkin, Orenstein, Offit eds. page 1642 Be respectful and solicit questions Be empathetic with parent s concerns Provide information specific to parent s fears Educate parents before the vaccine appointment Be informed about vaccine issues and misinformation to be able to respond confidently Strongly recommend vaccines in unambiguous language 77

78 Specific responses to parent type Vaccine 2005;23: ; Pediatrics 2008;122:718 No doubt indicators 71.7% Lower information needs, less time Ask questions Provide information Unsure 22.4% Higher information needs, more time Encourage dialogue and present a balanced view. Emphasize benefits of vaccination but discuss risks as well. Refuse 5.9% Low or no information needs, less time Is your decision firm? If so document or sign refusal waiver. Discuss consequences of not vaccinating. Remain open to discussion and provide information as requested. 78

79 What can we do? Remember the impact VPD had (and can have) on children Recognize misinformation and correct with facts Acknowledge parents fears and concerns Provide information on safety and efficacy of vaccination Use confident, forceful language in speaking with families (based on the evidence) Google: Matt Lauer and Nancy Snyderman on vaccines 79

80 Main reasons parents who planned to delay or not to get a vaccine for their child changed their minds Gust et al Pediatrics 2008;122:718 80

81 Questions? 81

82 Please Complete Online Evaluation! The online evaluation is a requirement for those of you seeking CME/CEU credit. 82

83 Resources AAP CA District IX www2.aap.org/immunization American Academy of Pediatrics Immunization Resources 83

84 Resources Immunization Action Coalition (August is National Immunization Awareness Month) 84

85 Resources Shot by Shot Stories of Vaccine Preventable Diseases 85

86 Thank you for your support and your participation! 86