Addressing Vaccine Hesitancy: Effective Interventions at the Provincial and Territorial Level

Transcription

1 Addressing Vaccine Hesitancy: Effective Interventions at the Provincial and Territorial Level Noni MacDonald MD FRCPc Canadian Centre for Vaccinology IWK Health Centre, Dalhousie University, Halifax, Nova Scotia June 16,2016

2 Conflicts of Interest No financial conflicts to declare My Biases: -Consultant to Canadian Peadiatric Society Imm/ID Cmt -Consultant/Advisor to WHO HQ Immunization/Vaccines and Biologicals -Canadian Centre for Vaccinology: Health Policy and Translation Group I believe vaccines are safe, effective, serious diseases can occur if not immunized 2

3 How Address Vaccine Hesitancy at Immunization Program Level? No magic bullet: -systematic review of strategies, gray literature ( ) & review of reviews - no one strategy to specifically overcome hesitancy in all populations - are strategies that improve vaccine uptake multi-component more effective than single 5A s recently emphasized access, affordability, awareness, acceptance, activation Jarrett C, Wilson R, O'Leary M, Eckersberger E, Larson HJ; SAGE Working Group on Vaccine Hesitancy. Vaccine 2015;33: Dube E, Gagnon D, MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine. 2015;33: Thomson A et al The 5As. A practical taxonomy for the determinants of vaccine Uptake Vaccine 2016 online Salmon DA et al Vaccine Hesitancy Causes, Consequences, and a Call to ActionAm J Prev Med 2015;49(6S4):S391 S398

4 6 Approaches to Enhance Vaccine Acceptance/Address Hesitancy At Provincial/Territorial Immunization Program Level 1. Detect and address hesitancy in subgroups 2. Ensure HCW best immunization practices 3. Utilize evidence based strategies known to uptake 4. Effective Communication plan 5. Educating children, youth, adults on the importance immunization for health 6. Work collaboratively 4

5 1. Detecting and Addressing Vaccine Hesitant Subgroups Reasons for hesitancy vary; - not uniform across population; - may change over time - vary by vaccine - may occur in clusters or pockets At program level: key to identify subgroups low immunization- hard if no immunization registry Medical and Non Medical Exemptions in Ontario Wilson SE et al Trends in medical and nonmedical immunization exemptions to measles-containing vaccine in Ontario: an annual cross-sectional assessment of students from school years 2002/03 to 2012/13 CMAJ Open 2015 ; 3:

6 WHO EUR: The Guide to Tailoring Immunization Program- TIP At Immunization Program Level: TIP framework 1) helps identify and prioritize vaccine hesitant populations and subgroups, 2) diagnose the demand and supply side barriers and enablers to vaccination in these vax hesitant populations 3) design evidence informed responses to vaccine hesitancy appropriate to the setting, context and hesitant population 4) Evaluate impact and outcomes. data/assets/pdf_file/0003 /187347/The-Guide-to- Tailoring-Immunization- Programmes-TIP.pdf Butler R, MacDonald N. Diagnosing the determinants of vaccine hesitancy in specific subgroups: Guide to Tailoring Immunization Programmes (TIP). Vaccine 2015;33:):4176-9

7 2. Educate all HCW in Best Immunization Practices HCW s own immunization status -reflects onto their patients status HCW vaccine beliefs: - influences whether families will come forward and/or accept immunization For optimal outcome parents, adolescents and adults need to hear from all HCW : - consistent, accurate information: vaccine preventable disease risks, vaccine safety & benefits - given in a respectful, positive manner HCP immunization education key Ensure HCW immunization up to date Zhang J et al Vaccine 2010, 28: (nurses); Collange F et al Hum Vac &Imm online Apr/16 ( FP); Favin M, et al International Health 2012; 4:

8 3. Use Most Effective Strategies to Vaccine Uptake a) directly target unvaccinated or under-vaccinated populations specific populations: e.g. local community, HCW; b) aim to increase knowledge, awareness about vaccination c) engage community leaders, religious or other influential leaders to promote vaccination in the community. UNICEF: BUILDING TRUST IN IMMUNIZATION Partnering with Religious Leaders and Groups d) improve convenience and access to vaccination; e) employ reminder and follow-up; f) mandate vaccinations / sanctions for non-vaccination, $$ incentives; Jarrett C, Wilson R, O Leary M, Eckersberger E, Larson et al. Strategies for addressing vaccine hesitancy. -a systematic review. Vaccine 2015; 33(34):

9 Religion and Vaccines Review of major religions of world -most religious doctrines support caring for others, preserving life having a duty to the community (family, neighbours, each other) i.e support vaccination - exception Christian Scientists - did not look at anthroposophical - Grabenstein JD. Vaccine 2013;31: WHO EURO Collaborative Project with Sweden: Hard-To-Serve pop 0ce868ba30.pdf Bystrom et al Vaccine 2014;32: Calgary bishop s HPV vaccine ban putting thousands of girls at risk: MDs National Post June 26, 2012 Guichon JR et al. Prev Med. 2013;57: Polio scare Israel 2014: multi pronged approach- including work with IMA, IPA, rabbis, imams etc Kaliner E et al. Euro Surveill. 2014;19(7):pii=20703

10 Ease of Access Matters Age Standardized Flu Vax Rates, Age > 12y 2003 vs 2014 in Canada HPV 3 dose Coverage among Girls in high income countries 2014/15 Flu vax uptake in schools in UK > than if pharmacy/gps Thompson A, Watson M Vaccine hesitancy: A vade mecum v1.0. Vaccine 2016 ahead of print ogramme_england_201415_end_of_season_report_final.pdf McConeghyy K, WingC. Vaccine 2016

11 Reminders Make a Difference Systematic review: effect on 0-5 years imm - postal and telephone reminders help Harvey H, Reissland N, & Mason J. Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis. Vaccine2015; 33(25): US: 3 text messages: flu vaccine uptake minority pop 1.risk of disease, vaccine safety 2 & 3. dates, place clinics Stockwell et al JAMA 2012; 307: Guatamala: SMS infant vax reminder for 2 nd, 3 rd vac visits Domek et al SMS text message reminders to improve infant vaccination coverage in Guatemala: a pilot Randomized controlled trial Vaccine 2016; 34:

12 Reminders / Information to Seniors Chicago: 2 min video on pneumococcal vaccines sent to seniors by phone prior to clinic visit - uptake - sent to 116 seniors before 1 0 care visit 75% opened 90% viewed at least at some; 64% whole video - If watched video 3 X more likely to accept vaccine Manitoba CMOH letter to all seniors re pneuomococcal vac- ran out of vaccine! Cameron K et al 2016 Society of General Internal Medicine Annual Meeting

13 Mandatory Vaccination and $ Incentives Mandatory Immunization for school entry e.g. USA, Australia (not New Zealand) Canada only 2 provinces Outcome: US- rates non medical exemptions; not lead to high uptake - may backfire UK- 150 years ago compulsory small pox vaccine: huge backlash Ont/ NB not > imm uptake rates than other provinces Incentives: HCW: UK GP imm incentives uptake sys review not enough evidence but where done like: Aust Dubov A, Phung C. Nudges or mandates? Ethics mandatory flu vac. Vaccine 2015;33: Salmon DA, et al. Making mandatory vaccination truly compulsory: well intentioned but ill conceived. Lancet Infect Dis Aug;15(8): Dube E, MacDonald NE. Addressing Vaccine Hesitancy and Refusals in Canada. CMAJ Sept 2015 DOI: /cmaj Hull et al British Journal of General Practice. 2000;50: Wigham etal. Pediatrics 2014;134:e

14 4. Effective Communication Plan Be proactive NOT just reactive Communication is a two-way process: listening is key Knowledge is important but not enough to change behaviour Choose knowledge that focus on carefully Know your target audience- tailor plan to fit Many communication tools available be selective, target appropriate, use creatively to promote vaccine uptake* Evaluate impact and adjust as need to Goldstein S, MacDonald NE, Guirguis S and the SAGE WG on Vaccine Hesitancy. Health communication and vaccine hesitancy. Vaccine 2015;33: Shelby A, Ernst K. Story and Science. Hum Vac and Immuno 2013; 9: *Odone et al Hum Vaccin Immunother 2015;11(1):72-82 (review effectiveness new media ) Thompson A, Watson M Vaccine hesitancy: A vade mecum v1.0. Vaccine 2016; 34:

15 Gateway to Beliefs Knowledge is NOT enough Research on climate change beliefs Belief in a scientific fact increases when consensus is highlighted Van der Linden, S et al How to communicate the scientific consensus on climate change: plain facts, pie charts or metaphors?. Climatic Change ; Underlining the scientific consensus on vaccine safety and efficacy maybe gateway to change or shape belief 15

16 Impact of Vaccine Messages: Varies Effectiveness varies with parental vaccine attitudes Nyhan B et al Pediatrics 2014;133; e Pro-vaccine messages: work for those who are favorable: important for resiliency but in unfavorable - not reduce vaccine misperceptions, nor increase uptake-i.e. backfire effect reinforce negative views Partisans see unfavorably slanted content as even more polarized than it is Gunther AC et al Comm Res 2012;39: Key: test messages in advance; tailor to fit 16

17 Targeted Messages Can Work Freemantle, Western Aust - low rates imm, esp amongst alternative lifestyle group I Immunize campaign -multi pronged - explicitly appealed to/ derived from: local values around social justice, parenting and alternative lifestyles - did polarize views: - BUT amongst alternative lifestyle group : now 77% +ve Attwell K, Freeman M. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. Vaccine 2015; 33:

18 Focus on Dangers VPD more Effective than Refuting Vaccine Myths 3 VPD messages a) mother s perspective on her child contacting measles b) Picture child with measles vaccine attitude pretest scores Stories are powerful condition Horne et al Countering antivaccination attitudespnas 2015;112: c) 3 short warnings about how imp to immunize against measles VS CDC summary studies MMR not cause autism-refute myth VS control other non vax scientific information 18

19 Fuzzy Trace Theory/ Gist & News on Facebook Broniatowski D et al. Effective vaccine communication during the disneyland measles outbreak. Vaccine 2016; 34:

20 Proposed Gist Communication Framework Verbatim Explicit Link GIST Establishes credibility and expertise Connects verbatim with GIST Helps comprehension and recall Evidence based fact or Statistic Scripted phase Bottom line meaning Broniatowski D et al. Vaccine 2016; 34: eg And the reason that s important is What that means to you is So the thing to remember is Bottom line -what I tell patients is

21 For the modern-day immunization program manager, the mantra needs to be: communicate, communicate, and then communicate some more..but be sure fit audience targeting Goldstein S, MacDonald NE, Guirguis S and the SAGE Working Group on Vaccine. Health communication and vaccine hesitancy. Vaccine 2015;33(34): In Canada- also need more uniformity across the country on immunization information Steenbeek A et al.ill-informed consent? A content analysis of physical risk disclosure in school-based HPV vaccine programs. Public Health Nurs. 2012;29:

22 5. Shape Children s Beliefs on Vaccine Necessity, Benefits, Safety Start early: Primary: what vaccines are, why needed, benefits, safety Secondary: weave into history, science and health Engage expert teachers and students - many resources Ontario has included child and youth vac edu in 2020 Imm plan Evidence can shape beliefs and behaviour of children - Bullying - Exercise initiatives - Environmental activism - Earth Sciences literacy (US) Earth Science Literacy Initiative, Earth Science Literacy Principles. The Big Ideas and Supporting Concepts of Earth Science. Online: s_literacy_6may10_.pdf, Teachers Kit, National Immunization Poster Contest in Canada. Opel D, Marcuse E. Human Vaccines & Immunotherapeutics 2013;9: Nowak G, Gellin B, MacDonald NE, Butler R et al Addressing vaccine hesitancy: The potential value of commercial andsocial marketing principles and practices Vaccine 2015; 33:

23 6. Work Collaboratively Partnership: Key Asset Prov/Terr Immunization programs PHAC Academia HCPs HCP societies: CPHA, CPS, AMMI etc Manufacturers Civil Society Organizations Private Sector: Pharmacies, companies Global agencies: WHO Mobilize and collaborate 3 shared objectives: (i) communicate proactively on immunization, (ii) prepare for issues that may arise (iii) understand the challenge better through existing and future research. saves time, resources, adds voice, enhances health worker vaccine message credibility Thompson A, Watson M Vaccine hesitancy: A vade mecum v1.0.vaccine 2016; 34 (17) :

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