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1 Communicating with Pregnant Women about Vaccines: Using the CASE Approach to Address Vaccine Hesitancy Robert M Jacobson, MD, FAAP Medical Director, Mayo Clinic s Primary Care Immunization Program Producer: Morgan Van Cleef 1 Webinar Guidelines 1 hour presentation including a discussion period at the end. Send your questions at any time during the presentation via the chat box on your screen. Webinar Guidelines This webinar will be recorded and available on demand for future viewing. Turn on your computer speakers for sound Handouts are available to download: www. vaccinateny.org 1

2 Continuing Education Credits CNE s, CME s and CHES : Please complete the post test and evaluation on The School of Public Health, University at Albany is an approved provider of continuing nurse education by the. American Nurses Association Massachusetts (ANA MASS), an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. This offering is approved for 1 nursing contact hour. The School of Public Health, University at Albany is accredited by the Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. The School of Public Health, University at Albany designates this live activity for a maximum of 1 AMA PRA Category 1 Credits TM. Physicians should claim credit commensurate with the extent of their participation in the activity. Sponsored by the School of Public Health, University at Albany, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to.5 total Category I contact education contact hours. Maximum advanced-level continuing education contact hours available are 0. This project is funded through a Memorandum of Understanding with the NYS Department of Health. There is no commercial interest funding this program. The planners and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials. Disclosures Potential conflicts Safety Review Committee Gardasil or 4-valent human papillomavirus vaccine in males (Merck) Gardasil 9 or 9-valent human papillomavirus vaccine (Merck) Data and Safety Monitoring Board Adult and infant 15-valent pneumococcal conjugate vaccine (Merck) No off-label use discussion 6 Learning Objectives Upon completion of this webinar, you will be able to Identify common perspectives shared among vaccine hesitant pregnant patients Discuss opportunities to communicate early and often with vaccine hesitant pregnant patients Describe how you can use the C.A.S.E. approach toward vaccine hesitancy Presenter Robert M Jacobson, MD, FAAP Medical Director, Mayo Clinic s Primary Care Immunization Program 7 2

3 Vaccines Due During Pregnancy Whooping Cough Tetanus-diphtheria-acellular pertussis Tdap Between 27 and 36 weeks, closer to 27 the better Primarily for preventing whooping cough in the baby Influenza vaccine IIV As soon as available that season Primarily for preventing flu in the pregnancy Pertussis Almost all deaths occur in 1 st 3 months of life Severe breathing difficulties Cardiorespiratory collapse Apnea Infant s immunity needs 3 doses over 6 months 9 10 Tdap Safe to receive in pregnancy Maternal antibodies highest 2 weeks later Antibodies decline steadily Best given 27 to 36 weeks gestation Closer to 27 weeks the better Protects baby in first six months Needs repeating every pregnancy Safe to receive every pregnancy Common Concerns Won t getting it during pregnancy put me at risk for miscarriage or premature delivery? No, studies show no risk of either Mothers-to-be tolerate the vaccine very well The vaccine contains no bacteria The vaccine cannot give the mother pertussis The most common reactions are mild Swelling, redness, and pain at the injection site These resolve without need for care

4 Another Common Concern Another Common Concern Won t a vaccine during pregnancy put my baby at risk for birth defects? No, no evidence exists despite numerous studies No vaccine bacterial, viral or toxoid has ever been show to cause a birth defect Even live vaccines, though we withhold their use in pregnancy for theoretical reasons Isn t pertussis a disease of the past? US now sees 10,000 to 50,000 cases a year Ten to 20 infants die each year in the US Almost all deaths in infants < 3 mos of age Current vaccine not at all long lasting Most adolescents and adults are no longer immune Contagion appears to require hours of exposure Source of infection primarily school children Another Common Concern Can t I just get it after delivery? No, mother can t transmit enough antibodies by breastfeeding Only given after pregnancy if mother never had Tdap Mother s protection alone not enough Even immune household members insufficient Best protection is vaccination at 27 to 36 weeks This allows mother to transfer immunity to baby The transferred immunity lasts 6 months Also this immunity doesn t interfere with baby s shots Influenza Pregnancy puts women at much higher risk when they catch the flu or influenza Disease severity Complications Hospitalization Death Premature labor and delivery

5 Influenza Vaccine IIV safe to receive in pregnancy Maternal antibodies highest 2 weeks later Antibodies last entire flu season Best given as soon as available Typical season August through May Any trimester is safe Can be given with Tdap if Tdap due too More on the Influenza Vaccine Protects mother thru entire pregnancy Protects baby in first 6 months Babies unable to get vaccine until 6 months Even then need 2 doses 1 month apart for immunity Needs repeating every season Safe to receive every pregnancy Don t use LAIV for theoretical reasons as it is a live vaccine Common Concerns Won t getting the flu vaccine during pregnancy put me at risk for miscarriage or premature delivery? No, studies show no risk of either Millions of pregnant women have gotten the flu vaccine over the years without safety issues Mothers-to-be tolerate the vaccine very well The vaccine contains no virus The vaccine cannot give the mother influenza The most common reactions are mild Swelling, redness, soreness, or tenderness at the injection site Some report muscle aches, headaches, fatigue, fever, or nausea These resolve without need for care Another Common Concern But I never get flu. Why should I bother? Most people get the flu at least once every 4-5 years Most people are not diagnosed though with the flu About half just have a mild illness The other half have fever with a cough or sore throat We rarely test unless at point of hospitalization

6 Another Common Concern How To Present the Vaccines I ve got really sick after previous doses of the flu vaccine. My friends have too. Coincidences are tricky Our minds look back at the last action we took Randomized controlled trials clarify The rates of really getting sick after a vaccine Is the same as in the placebo group Present them as strong recommendations Discuss them as Matter-of-fact Routine steps in obstetric care What you clearly recommend Presume acceptance the way you do with other steps of care Recs Perceived as Strong Are Better Rosenthal et al in to 26 year old females re HPV vaccine 1375 who had received 1 dose in 4 months Compared to 1375 who did not Rated recommendation 1 thru 5 in strength 1 did not strongly recommend the vaccine 5 strongly recommended the vaccine Strong rec 4 times more likely to get vaccine Why Presumptive Language? For Tdap and influenza vaccination in pregnancy These are not choices in the sense of choosing comfort care in labor where there are tradeoffs in benefits and risk These are not options where expert opinion is divided such as circumcision for male newborns

7 More on Presumptive Language Landmark Study Presumptive language better communicates your strong recommendation Data from recorded conversations with primary care clinicians, parents and patients support presumptive language Opel et al in parents of children aged 1 to 19 years of age Oversampled vaccine hesitant parents Videotaped health-maintenance visits 74% providers presumptive (eg, Well, we have to do some shots ) rather than participatory (eg, What do you want to do about shots? ) Odds of parents accepting if presumptive 17.5 times more than participatory! Who initiated the vaccine recommendation or plan specifically? (n =111) No plan verbalized (3%; n = 3) Parent (13%; n = 15) Clinician (84%; n = 93) How does the CLINICIAN initiate the vaccine recommendation? (n = 93) How does the CLINICIAN respond to parent resistance? (n = 38) Offers mitigated plan (21%; n = 8) Accepts (29%; n = 11) Pursues initial plan (50%; n = 19) How does the PARENT respond to clinician s continued pursuit of initial plan? Presumptive (74%; n = 69) Participatory (26%; n = 24) How does the PARENT respond to the provider s initiation? Accepts (47%; n = 9) Continued resistance (53%; n = 10) Accepts (74%; n = 51) Accepts (4%; n = 1) How does the CLINICIAN respond to continued parent resistance? (n = 10) Resists (26%; n = 18) Resists (83%; n = 20) Offers mitigated plan (40%; n = 4) Accepts (30%; n = 3) Continues pursuit of initial plan (30%; n = 3)

8 Repeated with HPV Vaccine Obstetric Offices and Vaccines Brewer et al in 2017 Randomized 30 pediatric and family med clinics No training (control), announcement (presumptive) training, or conversation (participatory) training 17,173 adolescents 11 or 12 years of age Six month increases in HPV vaccination larger for patients in clinics with announcement training Not all offices can stock vaccines Make a strong vaccine referral Begin each referral with info on why the vaccine is beneficial and safe for mother and baby Provide info on where patient can get vaccine Always write a patient-specific prescription More Tips Anticipate questions on why your office doesn t stock the vaccine Re-emphasize the vaccine s importance Have plan in place to answer questions from vaccine providers who are concerned with the safety of vaccinating your patients How to Address Vaccine Hesitancy Your strong recommendation matters Your addressing it early and often matters Your management of hesitancy matters too Don t give up or give in Use the C.A.S.E. approach Stop using the common approaches of the past

9 No, I won t be getting that vaccine today! I agree that there s a lot to consider. Let s talk about it further at our next visit! Let me give you some written information so you and your family can read more about the vaccine when you get home. The C.A.S.E. Approach Model for talking to vaccine-hesitant patients Organized, rapid, and useful response Created by Alison Tepper Singer Former NBC and CNBC television producer Mother of an autistic child Quit Autism Speaks over its anti-vaccine stance Founding CEO of Autism Science Foundation Strong advocate of science, vaccination

10 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 The C.A.S.E. Acronym Corroborate (pathos) About Me (ethos) Science (logos) Explain/Advise (telos) The C.A.S.E. Approach Corroborate: Identify and acknowledge the person s 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 Appeal to the reason why the person is talking to you Science: Relate what the science says, briefly Recognize that this is only a part of the response Explain/Advise: Explain your advice to patient, based on the science Do make your recommendation clear 39 No, I won t be getting that vaccine today! I do recommend it. Let me give you some material to read about it

11 No, we won t be doing that vaccine today! Why not? What is your specific concern? I m worried its just not safe while I m pregnant. I m just 12 weeks. I don t want to lose the baby! I understand. A lot of new mothers-tobe have that reaction at first. I thought the same thing when the recommendations first came out. But I read the studies, talked to the experts, and learned otherwise!

12 Some vaccines are not only safe to give in pregnancy, they benefit you and the baby. The flu is so hard on mothers-to-be. We need to do all to prevent it. Millions of pregnant women have received it proving it safe and effective. Vaccinating you today will reduce your chance of hospitalization or worse! The C.A.S.E. Approach So that s why I m recommending the flu vaccine to you today! 47 Corroborate: Why not? What is your specific concern? Lots of mothers-to-be have that reaction at first About Me: I felt the same way at first as well I read the studies, listened to the experts, learned otherwise Science: The vaccine s been proven safe in pregnancy And it benefits both your health and the baby s Explain/Advise: So that s why I m recommending you start today 48 12

13 Summary Identified common perspectives shared among vaccine hesitant pregnant patients Discussed opportunities to communicate early and often with vaccine hesitant pregnant patients Described how you can use the C.A.S.E. approach toward vaccine hesitancy Questions 49 Evaluation and Post-test Click here to fill out the evaluation and post-test for free continuing education credits. ( 13