Understanding and Addressing Vaccine Hesitancy

Transcription

1 UW Medicine SCHOOL OF MEDICINE Understanding and Addressing Vaccine Hesitancy Edgar K. Marcuse, MD, MPH

2 School Immunizations Exemptions Washington State School Entry Immunizations Exemptions <2.0% % % % % >10.0%

3 Poll Question Does your state s experience reflect that of Washington? A. Yes B. No C. Don t know D. I am from Washington

4 Types of Exemptions Religious Personal belief Medical only Source: Institute for Vaccine Safety

5 Poll Question Do you think personal belief exemptions correlate with vaccine coverage? A. Yes B. No

6 Immunization Coverage & Philosophic Exemptions Vaccine Coverage 4:3:1: Highest 10 rates Lowest 10 rates Philosophic exemptions for school or day care + National Immunization Survey U.S. 2009, vaccine series (modified)

7 Parents Have Doubts About Vaccines No vaccine doubt indicators 71.7% Vaccine doubt indicators 28.2% Unsure: 8.9% Delayed: 10.2% Refused: 1.6% Unsure & delayed: 3.2% Delayed & refused: 2.3% Unsure & refused: 0.4% Unsure, delayed & refused: 1.6% Refusal or delay vaccines increased from 22% (2003) to 39% (2008), even after adjusting for increased number of vaccines Gust DA, et al. Pediatrics. 2008;122: ; Smith PJ, et al. Poster, 2010 PAS Meeting, Vancouver BC

8 Diseases Perceived by the Public as a Threat to Personal and Public Health 1967 Smallpox DTP Polio (OPV) Measles Rubella

9 Diseases Perceived by the Public as a Threat to Personal and Public Health 1967 Smallpox DTP Polio (OPV) Measles Rubella 2007 DTaP, Tdap Polio (IPV) MMR Hib HepB HepA PCV13 MCV4 Influenza Rotavirus HPV

10 Parental Concerns 2011 Obesity Drug & alcohol abuse Smoking, tobacco use Teen pregnancy Bullying Internet safety Exposure to violence & sex Cyber bullying Stress School anxieties Adolescent depression Driving accidents Sexuality issues Sexting ; stereotyping Gangs, violence Environmental hazards High-fructose corn syrup Mercury, lead Hormones in meat, milk Pesticides Contaminated foods Phthalates & Bisphenol A Excess sun exposure Second-hand smoke Adapted from University of Michigan C.S. Mott Children s Hospital; National Poll on Children s Health, 2011

11 Origins of Immunization Hesitancy Social and Cultural Decline in vaccine-preventable diseases Recognition of the present limits of medicine, science, technology Resurgence of complementary and alternative medicine Growth of consumerism Malpractice and product liability litigation Adapted from Kane MA. Vaccine 1998;S73-S78

12 Origins of Immunization Hesitancy Science, Media, and the Internet Distortion of scientific process Science: hypothesis test accept or reject refine Media: hypothesis validated by repetition Differing criteria for causality Medical, legal, public opinion Challenge of risk communication Science vs. freelance and feature writers; talk radio Access to media, Internet Credibility of source, media concept of balance, utility to media of controversy Adapted from Kane MA. Vaccine 1998;S73-S78

13 Parents want to do what is best for their child but face a conundrum: What to believe? S O F T B A L L Community Parents Providers H A R D B A L L Public health Media/ Internet Antivaccine

14 Parents Who Refuse Vaccines Compared to parents who immunize their children, parents who refuse vaccines generally are Older, better educated, non-hispanic white Concerns about vaccine safety Cause harm 69% Overload immune systems 49% Child not at risk for disease 37% Disease not dangerous 21% Salmon DA, et al. Arch Pediatr Adolesc Med 2005;159: ; Bardenheier B, et al. Arch Pediatr Adolesc Med 2004;158: Gust DA, et al. Pediatrics 2008;122: : Freed GL, et al. Pediatrics 2010:125:

15 Parents Vaccine Concerns Vaccine concerns reported by parents of children age 6 or younger, 2010 Too many/once Too many/general Cause fevers Cause autism Ingredients unsafe Not tested enough Cause disease Low risk for disease Disease not serious Parents reporting concern (%) Adapted from D Opel; 2011; Kennedy et al. Health Affairs 2011

16 Science Essential, But Not Sufficient Safety concerns often fear- or faith-based; not easily refuted by science Fear of environmental toxins Fear of the medical-industrial complex Lack of trust in integrity of government science Faith in trusted spokespersons Faith in alternative health beliefs Good vaccine science is essential, but not sufficient Good science is complex, takes time, conclusions change as evidence evolves, and junk science abounds Safety concerns advanced as scientifically plausible

17 What Level of Vaccine Safety Is Required? Safety is relative, not absolute Can reject, but not prove, the null hypothesis Cannot prove: there is no association between a vaccine and an adverse event Can conclude only: there is no evidence of an association What disease risk balanced by what assurance of vaccine safety and efficacy justifies a mandate?

18 Balance of Benefits and Burdens What should be balance between State s duty to protect the public health Individual s right of free choice When does risk to public health trump free choice? Adapted from Feudtner C, Marcuse E. Pediatrics 2001;107:

19 Poll Question Who do you think should decide? A. Scientists B. Judges C. Legislators D. Public Health Officials

20 Barriers to Parent-Provider Communication About Immunization Hesitant parents May be reluctant to question or challenge Want open dialogue about pros & cons Not receptive to public health benefit messages Providers Time constraints May not be up-to-date on safety concerns Fear becoming enmeshed in debate Feel responsible for protecting infant VAX Northwest 2009: Survey of vaccine-hesitant mothers & provider interviews

21 Why Parents Change Their Minds % of Parents Information or assurances from child's doctor Just thought more about it Info from some other source 10% 14% 22% 37% Doctor refused to treat/daycare wouldn't admit Discussion with spouse/relative Other Don't know Adapted from D Opel, 2011; Gust et al, Pediatrics, 2008

22 Provider Messages for Parents I understand that you want to do what is best for your child; so do I! Many parents feel bombarded with conflicting information and do not know whom to believe. I recognize that science does not provide answers to all the questions that concern you but science is the best tool we have to get reliable answers to important questions. I wish we could make the world completely safe for your child; I cannot.

23 Provider Messages for Parents There are important threats to your child's health and safety we cannot eliminate, but I can help you protect your child. I can help you get the information you need to decide to protect your child against serious diseases that can result in lifelong disability. To help you make a fully informed decision about immunizations, here are some sciencebased information sources, unrelated to drug companies.

24 Vax Northwest: Community Intervention Rationale* Parents gather information and form opinions through social networks The voice of immunizing parents is unheard Immunizing parents understand and recognize the value of a healthy community When given compelling information, immunizing parents become activated Goal Stimulate peer-to-peer communication about the value of a fully vaccinated community *Based on VAX Northwest 2010 focus groups of immunizing parents

25 Vax Northwest: Community Intervention Planned elements Parent volunteer health advocates Localized campaigns Technical support from Vax Northwest Community-specific action toolkits Peer-to-peer communications, social media, school events, newsletters Use of targeted, local media to reinforce Planned evaluation Parent surveys and focus groups, media monitoring, key informant interviews

26 Experts Infectious disease Epidemiology Public health clinicians Professional organizations (AAP, AAFP, NMA, ANA) Federal agencies (CDC, FDA, NIH, DOD) Public health policy State, local health dept

27 Industry Advocacy groups Experts Infectious disease Epidemiology Public health clinicians Professional organizations (AAP, AAFP, NMA, ANA) Federal agencies (CDC, FDA, NIH, DOD) Public health policy State, local health dept Media Events

28 New Public Engagement Initiative ACIP s* new recommendation scheme A: All persons in an age- or risk-specific group B: Individual clinical decision-making Public engagement on MCV4* vaccines in children 2 10 years Multiple MCV4 vaccine to be licensed for children Lacks a type B meningococcal component Responsible for about half of disease in age group Cost-effectiveness may be marginal * ACIP: Advisory Committee on Immunization Practice MCV4: Meningococcal Conjugate Vaccine 4 Components

29 Questions? US Public Heath Service based on quarantine Q signal flag First US Naval Jack, 1775