Vaccine Hesitancy. Michelle P. Medina, MD, FAAP Interim Chair, Department of Community and General Pediatrics, Cleveland Clinic Childrens

Transcription

1 Vaccine Hesitancy Michelle P. Medina, MD, FAAP Interim Chair, Department of Community and General Pediatrics, Cleveland Clinic Childrens October 20, 2016

2 Objectives Present a historical perspective of vaccine refusal/hesitancy Present current state of vaccine refusal/hesitancy Discuss methods to address vaccine refusal/hesitancy

3 Butterworth H. The Story of America Ushistoryimages.com

4 Gaston Theodore-Melingue wikigallery

5 Eytinge S images from the History of Medicine US National Library of Medicine

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7 Anti Vaccine Campaigns Vaccination Act of 1853 UK: vaccination compulsory for infants; parents are liable Anti-Vaccination League founded 1853 Vaccination Act of 1867: extended compulsory vaccination to age 14 Anti-Compulsory Vaccination League formed 1867 Vaccine Act tramples upon the rights of parents to protect their children Parliament has invaded the liberty of citizens by rendering good health a crime

8 Anti Vaccine Campaigns Royal Commission Report 1896 Investigate grievances of antivaccinationists Concluded that vaccination protected against smallpox BUT abolished cumulative penalties Vaccination Act 1898 introduced a conscience clause, allowing parents who did not believe vaccination was efficacious or safe to obtain a certificate of exemption ( conscientious objector )

9 Anti Vaccine Campaigns in the Americas New formulation 1850 precluding arm to arm passage of vaccine Longer shelf life Enabled worldwide distribution Renewed vaccination efforts 1870 s in North America due to resurgence of smallpox Formation of new anti-vaccination leagues Anti Vaccination Society of America 1879 New England Anticompulsory Vaccination League 1882 Anti-Vaccination League New York City 1885 Court battles, riots to repeal compulsory vaccine laws

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11 Anti Vaccination Arguments: Past & Present Cause Idiopathic Illness 1878 The National Anti- Compulsory Vaccination Reporter (Cheltenham, England) Among the dangerous illnesses following the vaccine process are diphtheria, erysipelas, and not unfrequently abscesses. On the whole it is a greater evil to humanity than small-pox itself! 2001 Anti-vaccination websites The documented long term adverse effects of vaccines include chronic immunological and neurological disorders such as autism, hyperactivity, attention deficit disorders, dyslexia, allergies, cancer, and other conditions, many of which barely existed 30 years ago before mass vaccination programs. Wolfe, Sharp. Antivaccinationists Past & Present. BMJ. 2002;325.

12 Anti Vaccination Arguments: Past & Present Poisonous Chemical Cocktails 1878 The mind that cultivates small-pox by vaccination is now engaged in the suppression of small-pox by saturating the small-pox with carbolic acid, which is a virulent poison. This poison being absorbed by the absorbents enters the blood, and the natural secretions are tainted by it The vaccines contain not only live viruses but also very significant amounts of highly toxic substances such as mercury, aluminum and formaldehyde. Could this be the reason for the upsurge in autism, ADHD, asthma, arthritis, Crohn s disease, lupus and other chronic disorders?

13 Anti Vaccination Arguments: Past & Present Cover Up 1878 Vaccine partisans are afraid of the "search after truth," and they fear the unveiling of error. Therefore do they close their eyes to facts and their ears to enquiry 2001 The cover-up of immune system failure following vaccination is reminiscent of the tobacco industry s continuous denial and misinformation campaign about the dangers of cigarettes

14 Anti Vaccination Arguments: Past & Present Healthy Lifestyle Alternative 1878 Is not vaccination a substitute, necessarily futile, for faithful obedience to the sacred laws of health, whereby alone health can be conserved and disease prevented? 2001 personal hygiene and diet stop diseases, folks, not injecting virulent free-floating genetic material into your veins with all kinds of poisonous cancerous carrying agents which is what vaccines are

15 Smallpox Declared Eradicated December 1979 Photos courtesy of CDC Dr. JD Millar, Robert Baldwin

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21 Rekindling the Debate House Committee on Government Reform, Vaccine Hearings (Finding The Balance Between Public Safety And Personal Choice) HHS resolution to study vaccine safety National Vaccine Advisory Committee, CDC, 2009 Drafted scientific agenda to study overall vaccine safety Institute of Medicine Report, 2013 Expressed support for the childhood immunization schedule Recommended using healthcare records data to continue to study the safety of vaccines, and that requiring children to be less than fully immunized for study is unethical Recommended stakeholder involvement in immunization schedule development

22 Vaccine Refusers in the 21 st Century BMC Pediatrics, 2009: Well educated, higher average household incomes Do NOT opt out of medical services Matern Child Health J, 2008: Postpartum mother 29% had concerns about vaccinating, regardless of eventual decision to vaccinate Less trustful: Mothers who were planning to breastfeed, just delivered their first baby, or had an income < $40,000 Pediatrics, 2006 Mother s decision-making highly influenced by trust relationship with pediatric provider

23 US Efforts National Vaccine Advisory Vaccine Confidence Group, CDC, 2015 Report on public confidence around vaccines nearly 12% of parents refuse at least one recommended childhood vaccine 30% delay one or more vaccines exemptions obtained for personal reasons from school immunization requirements have been increasing Set research and policy agenda Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee. June 10, 2015.

24 Evolution of Vaccine Confidence Chen RT, Orenstein WA.. Epidemiol Rev. 1996;18(2):102.

25 A Global Problem

26 WHO Efforts The Strategic Advisory Group of Experts (SAGE) on Immunization was established by the Director-General of the World Health Organization in 1999 to provide guidance on vaccine strategy for all vaccinepreventable diseases research and development of vaccines delivery of immunization and its linkages with other health interventions In 2012, convened Working Group on Vaccine Hesitancy MacDonald. SAGE Working Group on Vaccine Hesitancy. Vaccine. April 2015.

27 World Health Organization (WHO) Definition Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific varying across time, place and vaccines. It includes factors such as complacency, convenience and confidence.

28 Vaccine Hesitancy Model COMPLACENCY CONFIDENCE CONVENIENCE

29 Vaccine Hesitancy versus Vaccine Demand

30 Conceptual Model of Vaccine Hesitancy Dube, et al. Hum Vaccin Immunother Aug;9(8):

31 Strategies to address Vaccine Hesitancy Sadaf, VACCINE, Review of Interventions for reducing Parental Vaccine Refusal, 2013 Mostly US studies, 30 studies included (15,139), few RCT 3 categories of interventions: Passage of state exemption laws State and school-level implementation of laws Parent-centered immunization information/education NO convincing evidence of effective interventions Increasing options for obtaining nonmedical exemptions and increased ease INCREASE overall likelihood of nonvaccination

32 Strategies to address Vaccine Hesitancy Jarrett, VACCINE, Strategies for addressing vaccine hesitancy, 2015 Arose from SAGE Working Group on Vaccine Hesitancy 181 studies reviewed (37,919), US & international studies Most effective interventions employed multiple strategies

33 Strategies to address Vaccine Hesitancy Jarrett, VACCINE, Strategies for addressing vaccine hesitancy, 2015 Largest observed increase in vaccine uptake (>25%) Directly targeted under- or unvaccinated Increased vaccination knowledge & awareness Improved convenience & access to vaccination Targeted healthcare workers Mandated vaccinations or sanction against nonvaccination Engaged religious or influential leaders

34 Strategies to address Vaccine Hesitancy Jarrett, VACCINE, Strategies for addressing vaccine hesitancy, 2015 Largest observed increase in vaccine knowledge, awareness or attitude (>20%) Education initiatives, esp embedded initiatives (ie, into hospital processes) Least successful (< 10% increase in uptake) Focused on QI data collection & monitoring Passive interventions (posters, websites) Incentive-based interventions Reminder/ recall variable effect

35 Strategies to address Vaccine Hesitancy Engagement of religious or other influential leaders to promote vaccination in the community Social mobilization Mass media Improving convenience and access to vaccination Mandating vaccinations / sanctions for non-vaccination Employing reminder and follow-up Communications training for Health Care Workers Non-financial incentives Aim to increase knowledge, awareness about vaccination

36 SUMMARY Vaccine hesitancy has a long complex history Vaccine hesitancy is heterogenous, complex and context-specific Improving vaccine and vaccination confidence involves the use of multiple strategies Involve leadership Engage healthcare workers at every level Engage parents/ families at every opportunity Provide robust vaccine education program for families and healthcare workers

37 Atul Gawande The New Yorker July 29, 2013 SLOW IDEAS Leadership Summit October 13, 2015

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