HOW TO TALK ABOUT VACCINES. MIAP Pediatric Immunization Skills Building Conference October 18, 2018

Transcription

1 HOW TO TALK ABOUT VACCINES Rebecca Vanucci, MA Immunization Outreach Coordinator Massachusetts Department of Public Health Everett Lamm, MD, FAAP Chief Medical Officer Community Health Programs MIAP Pediatric Immunization Skills Building Conference October 18,

2 Disclosure. We, Rebecca Vanucci and Everett Lamm, have been asked to disclose any significant relationships with commercial entities that are either providing financial support for this program or whose products or services are mentioned during our presentations. We have no relationships to disclose. We may discuss the use of vaccines in a manner not approved by the U.S. Food and Drug Administration. But in full accordance with ACIP recommendations. Photos borrowed with permission from: nonprofitquarterly.org gettyimages.com 2

3 Vaccine Confidence Background Immunization Communication Environment Answers to Common Myths Communication Techniques Resources and Questions 3

4 When you hear the word vaccine what first comes to mind? 4

5 Vaccine Benefits Individual Community 5

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8 Vaccines Protect Public Health We all have a public health commitment to protect each other and each other s children by vaccinating our own family members. Photo Credit: National Institute of Allergy and Infectious Diseases 8

9 VACCINE CONFIDENCE BACKGROUND 9

10 Recommended Vaccines Providers who administer vaccines Vaccine Confidence Process that leads to vaccine licensure and recommendations National Vaccine Advisory Committee, Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, December Report found at: 10

11 Vaccine Confidence used to look a lot like this 11

12 But recently, we have seen some shifting 12

13 So, what s happening? Disease outbreaks Pertussis Measles Mumps Meningococcal disease outbreaks at college campuses More, different vaccine voices Parent advocacy groups in favor of vaccines Social Media platform Andrew Wakefield 1998 MMR-Autism Study discredited Fully retracted Only looked at kids displaying signs of autism More than 20 studies after looked at the connection and showed no link between MMR and autism 13

14 Rate (per 100,000) of Confirmed Pertussis Case for Franklin County and Massachusetts Statewide by Year, Franklin County Statewide Source: Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, Office of Integrated Surveillance and Informatics Services Rates are based on 2010 US Census data Data are current as of 9/11/2018 and are subject to change 14

15 Source: World Health Organization, Measles and Rubella Surveillance Data, Access on August 31,

16 So what s the good news? 16

17 Estimated Vaccination Coverage with Individual Vaccines Among Children Months of Age in MA, NIS Coverage 2017 Coverage Percent difference 4+ DTP 94% 93% Polio 100% 96% MMR 99% 98% Hib 99% 94% -4.8 Hib-FS 93% 89% Hep B 97% 93% -3.9 HepB birth dose 73% 77% Var 97% 98% PCV 98% 97% PCV 95% 92% HepA 67% 57% Rotavirus 85% 80% -4.6 NIS Data, CDC MDPH

18 Why even focus on Vaccine Confidence? Parents Providers 1 in 5 parents not fully confident National estimates mask local conditions While Massachusetts has high vaccination rates (even higher than the US for some vaccines), some areas of MA have higher exemption rates and may be susceptible to vaccinepreventable diseases. 93% reported some parents of children 2 years and younger requested to spread out vaccines 21% reported over 10% of parents made this request. National Vaccine Advisory Committee, Assessing the State of Vaccine Confidence in the United States: Recommendations from the National Vaccine Advisory Committee, Public Health Reports, November-December 2015, Volume 130 Kempe, A. et. al, Physician Response to Parental Requests to Spread Out the Recommended Vaccine Schedule, Pediatrics Volume 135, number 4, April

19 Immunizations A Complex Communication Environment Low disease awareness = increased focus on vaccine risks Low tolerance for vaccine risks Full and complicated immunization schedule Time is often limited Many places to find and get information 1 Brunson EK. The impact of social networks on parents' vaccination decisions. Pediatrics. 2013;131(5):e Smith PJ, Kennedy AM, Wooten K, Gust DA, Pickering LK. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics. 2006;118(5):e

20 Who is really talking online? Washington Post article, August 23, 2018 Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate published in American Journal of Public Health Russian trolls Tweeted about vaccines 22x the average Twitter user Wrote both positive and negative vaccine content attempt to amplify discord Also linked the vaccine debate to other divisions in American society, such as class and racial divisions Bots Focused on malicious software More likely to discuss harm of vaccines to generate clicks and downloads of the software 20

21 Research shows parents are confident in The safety of vaccines The effectiveness of vaccines The benefits of vaccines The number of vaccines their child gets in the first 2 years of life 21

22 But they still might be anxious about the shot visit About 25% of parents report having at least a little anxiety They may still have questions 22

23 We need more how There has been a lot of research on parents knowledge, attitudes, beliefs Little research on what communication techniques actually change parents behavior We ve been focused more on the what more than the how 23

24 Our Communication Assumptions May Be Wrong Improved knowledge Better decisions Known as the Information Deficit Model If only she just understood the facts she d realize she s making the wrong choice. Humans are rationale? Vaccination decisions are often based on emotion, not logic, reason, or facts 24

25 Vaccine Confidence Project Target Areas of Lower Vaccine Confidence Meet with Providers, Local Public Health, School Nurses, & Advocates Develop specific training for providers Expand on general training for public Larger presentations for both providers & public Contact Rebecca Vanucci or Cynthia McReynolds if interested 25

26 Religious and Medical Exemptions Among Massachusetts Kindergarten Students % with Exemptions N=853 N=687 N=166 Year Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March

27 Kindergarten Total Exemption Rates by County, Dukes % Exemption Rate MA State Average: 1.35% Suffolk Essex Norfolk Bristol Middlesex Worcester Plymouth Hampden Berkshire Barnstable Hampshire Franklin Nantucket Source: Massachusetts Annual Kindergarten Immunization Survey MDPH March

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31 Using school data to address vaccine confidence Look up your school s immunization rates Fortunate to live in an area of high imm. rates However, there can still be pockets of un or underimmunized children Need to keep high rates to protect kids Be an advocate! Our area may be susceptible to VPD and outbreaks Important to vaccinate your child on rec d immunization schedule Please tell your friends Be an advocate! 31

32 Common Patterns for People Lacking Vaccine Confidence Part 1 Feeling a lack of control or needing to be in control of health outcomes Difficult life event, such as a natural disaster, losing a job, or becoming ill Protect family through easily controlled means Need to understand how vaccines are studied and tested A negative healthcare experience in the past Disappointing or traumatic birth can influence mother s relationship to medicine Loved one suffering in past because of poor medical care Build a trusting relationship between doctor and patient Buying into a particular parenting style Organic, natural lifestyle and children are an expression of their lifestyle Refusing vaccines is a way of fitting in to some parenting groups Introduce parenting resources that support evidence-based approaches

33 Common Patterns for People Lacking Vaccine Confidence Part 2 Distrust of government or corporations Vaccines as government overreach Belief that it is a profitdriven scheme by pharmaceutical companies Understand benefits of vaccine schedule; Image of profits from vaccines Flawed risk assessment involving vaccines and diseases If a parent does something and a bad thing occurs, they can t live with the guilt Believe that the risks of vaccinating are higher than the risk of the vaccine Show risk of not vaccinating and how disease affects children Chemophobia Fear of chemicals extends to vaccines Marketing of all-natural and organic products Know the science of antigens, vaccine ingredients, and how they naturally work with the body s immune system

34 Success of vaccines means we don t see these serious diseases as much Image from Every Child by Two, State of the ImmUnion Report, 2018, 34

35 Herd Immunity Varies by Disease 35

36 HOW TO DO IT? Guide to increasing vaccine confidence in your practice 36

37 Communicating with Parents About Pediatric Vacc nes: Should this be a painful topic? 37

38 Verbalize why childhood vaccines are offered Articulate how vaccines work Consider the diseases vaccines protect against Cite controversies surrounding vaccines Identify specific parental concerns with vaccines Note varying levels of parental vaccine confidence Evaluate current immunization recommendations See that this should not be such a sore subject! 38

39 Vaccines are the safe, proven way to protect yourself and your family The United States currently has the safest vaccine supply in its history Before a vaccine is approved and given to children, it is tested extensively Scientists and medical professionals carefully evaluate all the available information about the vaccine to determine its safety and effectiveness As new information and science become available, vaccine recommendations are updated Children may experience some discomfort or tenderness at injection sites This is minor compared to the serious complications that can result from the diseases these vaccines prevent Serious side effects from vaccines are very rare 39

40 COMMON MYTHS ABOUT VACCINES 40

41 41 MYTH: MMR causes autism 1998: study was based on preselected 12 children 2004: 10 of the 13 authors of this study retracted the study s interpretation February 2, 2010: The Lancet retracted the paper Wakefield was removed from the U.K. medical register and is no longer licensed to practice medicine January 2011: the BMJ published a series of articles showing Wakefield s work was not just bad science, but deliberately fraudulant Immunization Action Coalition, MMR vaccine does not cause autism. Examine the evidence!

42 MYTH: MMR causes autism (continued) Many large, well-designed studies have found no link between MMR and autism Autism usually becomes apparent around the same time MMR is given no evidence of causality Autism probably has multiple components, including genetic predisposition e.g., one study found that if one identical twin had autism, the chance that the second twin had autism was greater than 90%, but with fraternal twins the chance was less than 10% Immunization Action Coalition, MMR vaccine does not cause autism. Examine the evidence! Photo borrowed with permission from phys.org 42

43 MYTH: Giving an infant multiple vaccines can overwhelm the immune system 43 Babies are immediately exposed to countless immunological challenges at birth Vaccines use only a tiny proportion of a baby s immune system s ability to respond Though children receive more vaccines than in the past, today s vaccines contain fewer antigens than previous vaccines Year Number of Vaccine Preventable Diseases Antigens (Smallpox) ~ Too Many Vaccines? What you should know (Vaccine Education Center, Children s Hospital of Philadelphia VEC)

44 Too many vaccines too soon? Irony: Our parents took much greater risk when getting us vaccinated back in the 195 s, 196 s, 197 s Today s children receive much safer, smarter vaccines which provide better protection than ever Vaccines do not weaken the immune system they boost it! 44

45 MYTH: It s better to space out vaccines using an alternative schedule Delaying vaccines increases the time children will be susceptible to diseases In 2014, there were 667 cases of measles reported in the US Majority of people who got measles were unvaccinated In 2014, 32,971 cases of pertussis were reported to CDC, and many more cases went undiagnosed Extra visits during busy office times More likely to induce stress/needle phobia and expose to other infectious disease AAP s The Childhood Immunization Schedule: Why Is It Like That? Vaccineschedule.pdf 45

46 Space out Vaccines & Lose the additives? Dr. Sears argues for spacing out vaccines to avoid giving infants too much aluminum at one time: When a baby gets the first big round of shots at two months, the total aluminum dose can vary from 295 micrograms... to a whopping 1225 micrograms if the higher aluminum brands are used and a hep B vaccine is also given...these doses are also repeated at four and six months. Photo courtesy of amazon.com 46

47 Delaying/spacing out vaccinations Leaves children unprotected for longer periods Puts children and contacts at increased risk for disease Greatly increases number of - required office visits - chances for error - painful experiences - total number of vaccines given Logistical problems created by so many office visits Increases risk of error Deviation from standard administration practice Limits combination vaccines Increase average age received Decreases the vaccine rate! Partnering with Parents to Achieve Immunization Goals. Summer

48 Alternative Schedules If more parents insist on alternate schedules (such as Dr. Sears ): Children will be more susceptible to vaccine-preventable diseases for an increased amount of time Fewer children will be protected So in an effort to protect their children parents will place more children in harm s way Pediatrics 2009;123;e164-e169 48

49 How to make shots visits less stressful 49

50 MYTH: Natural infection is better than immunization Natural infection may cause better immunity than vaccination However, the price paid for natural disease can include paralysis permanent brain damage liver failure liver cancer deafness blindness loss of limbs death Real-life accounts of people who have suffered or died from vaccinepreventable diseases 50

51 How vaccines work: Exposure to Disease Natural infection prevents disease well however you have to get sick before you become immune! CDC: parents guide to childhood immunizations

52 How vaccines work Vaccines help to develop immunity without getting you sick first CDC: parents guide to childhood immunizations

53 When should the bike helmet go on? A B C 53

54 MYTH: Thimerosal causes autism 54 The form of mercury found in thimerosal is ethyl mercury (EM), not methyl mercury (MM). Methyl mercury is the form that has been shown to damage the nervous system Although no evidence of harm has ever been demonstrated, thimerosal was taken out of vaccines as a precaution and because it can be (due to single-dose vials) Since 2001, with the exception of a few influenza vaccine products, thimerosal has not been used as a preservative in any routinely recommended childhood vaccines Regardless, multiple studies have repeatedly shown that thimerosal in vaccines does not cause autism Immunization Action Coalition collection of thimerosal-related resources

55 Thimerosol & Autism? Some parents, researchers and others have expressed concerns about links between autism and vaccines containing thimerosal There is no convincing evidence of harm caused by the small amounts of thimerosal in vaccines except for minor effects like swelling and redness at injection sites due to sensitivity to thimerosol Photo courtesy of 55

56 Thimerosol & Autism? July 2006 study published in Montreal Natural experiment occurred in when quantities of thimerosol in vaccines varied : babies rec d 125 micrograms : babies rec d 225 micrograms After 1996: babies received 0 micrograms Fombonne E., et al. Pervasive developmental disorders in Montreal, Quebec, Canada: Prevalence and links with immunization, Pediatrics118: ,

57 Thimerosol & Autism? If thimerosol causes autism the incidence should have been much higher in children born between than children born after 1995 The opposite is in fact true! incidence of autism is much higher in babies born after 1995 the increase in autism rates was at that time and continues to be most likely due to a broadening of the disease s definition Fombonne E., et al. Pervasive developmental disorders in Montreal, Quebec, Canada: Prevalence and links with immunization, Pediatrics118: , Photo used with permission by bookmarkurl.info 57

58 Vaccines and Controversy? Let s consider the following related events That: Some toddlers who wear Some toddlers who drink Some toddlers who hang out with parents who use Have been diagnosed with an autism spectrum disorder 58

59 Vaccines and Controversy? So do we need to consider and study that perhaps diapers, whole milk or cell phones cause autism as well? Photo borrowed from 59

60 MYTH: Ingredients in vaccines are harmful Additives such as gelatin, albumin, sucrose, lactose, MSG, and glycine help the vaccine stay effective while being stored Aluminum Used in some vaccines as an adjuvant an ingredient that improves the immune response Aluminum is the most common metal found in nature Most of the aluminum taken into the body is quickly eliminated 60 CHOP Vaccine Education Center, Aluminum in Vaccines: What you should know

61 Lose the Additives? Sounds reasonable... But it doesn t mean current vaccines are unsafe Additives like aluminum are in extremely small amounts (typically trace) compared to dietary intake Aluminum is the most abundant metal in the earth's crust and it is widely distributed Babies routinely ingest aluminum 50 mcg per liter of breast milk 500 mcg per liter of formula Pediatrics 2009;123;e164-e169 61

62 Lose the Additives? Antiperspirants contain aluminum So does most food, soil and water Aluminum poisoning does not cause autism-like symptoms (lung, bone and kidney disease) Trace amounts (far less than babies consume every day) actually improve the body s response to some vaccines 62

63 Lose the additives? However, alarmists & critics like Dr. Sears fails to put these numbers in context By 6 months of age, infants will typically ingest the following amounts of aluminum: 6,700 micrograms in breast milk 37,800 micrograms in infant formula 116,000 micrograms in soy-based formula He neglected to describe scientific studies that led the National Vaccine Program Office to conclude that the amount of aluminum in vaccines did not warrant changing the vaccine schedule Eickoff TC, Myers M. Workshop Summary: Aluminum in Vaccines. Vaccine. 2002;20:S1-S4. Pediatrics 2009;123;e164-e169 63

64 Lose the Additives? Why formaldehyde? Small amounts sterilize vaccine fluid Prevent children from getting bacteria -- like flesh-eating strep when receiving shots Obviously large exposure is not a good thing Paper towels, mascara, carpeting???? By comparison quantities in vaccines are extremely small Trying to make vaccines without adjuvants, additives, and preservatives is difficult these ingredients keep vaccines safe and effective 64

65 MYTH: Disease rates have dropped due to factors other than vaccination 65 Better living conditions (less crowded housing, better nutrition, clean water) have had an impact on disease rates BUT, the only real decreases in vaccine preventable diseases have occurred after the introduction of a vaccine to prevent it This is also true for newer vaccines like Hib (1987) and varicella (1995), which were introduced during times of modern hygiene When some developed countries (U.K., Sweden, Japan) stopped using DTP vaccine, their pertussis rates jumped dramatically Several recent outbreaks (measles, pertussis, and varicella) in the U.S. have been traced to pockets of unvaccinated children in states that allow personal belief exemptions When vaccination rates go down, disease rates predictably go up HHS s Vaccines Are Effective CDC s What Would Happen If We Stopped Vaccinations?

66 Before Measles Vaccine Nearly all kids got measles by age 15! Yearly in the US, approximately 450 people died because of measles 48,000 were hospitalized 7,000 had seizures about 1,000 suffered permanent brain damage or deafness CDC: parents guide to childhood immunizations 66

67 Why Immunize? Measles 1962, year before vaccine introduced 500,000 or more cases in US ,000 cases 1982 Fewer than 2,000 cases reported cases ww.cdc.gov 67

68 Measles - United States, ( Vaccine Licensed 68

69 Why Immunize? Measles 50 years ago one of most common childhood illness Today most parents will never know a child with measles Most doctors in US may never see a case Worldwide 23 million people still infected yearly 480,000 deaths yearly 69

70 Mumps Viral illness Parotitis and orchitis were described by Hippocrates in 5th century BCE Viral etiology described by Johnson and Goodpasture in 1934 Frequent cause of outbreaks among military personnel in prevaccine era Easily spread through the air Pre-vaccine ,000 cases a year Uncommon by cases, and then? 70

71 Mumps Best known for cheek and jaw swelling due to inflammation of the salivary glands Also causes a fever and headache It is usually a mild disease, but leads to meningitis (1 in 10 children) occasionally causes encephalitis causes sterility in males causes deafness (about 1 in 20,000 cases) death (1 in 10,000 cases) 71

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74 MYTH: Vaccines are not effective 74 Most childhood vaccines are very effective (~80% 100%) when properly administered and all doses are received according to the recommended schedule Some vaccines recommended for adults are not as effective as the childhood vaccines Adults, especially elderly adults, have less robust immune systems and may have a lower protective immune response after vaccination However even though these vaccines do not prevent all cases, they still have been shown to provide important protection HHS s Vaccines Are Effective CDC s What Would Happen If We Stopped Vaccinations?

75 So what to say to patients and parents? Talk about the benefits of vaccines List the benefits that vaccines have on the community By following the recommended childhood immunization schedule, Vaccinating your your child child will have not only protects protection her from against serious 14 serious diseases, but protects vaccine-preventable those who are diseases too young to be vaccinated by or age people 2. with weakened immune systems and the elderly, who are at risk for serious complications and death. Show the risks of vaccinepreventable diseases Make a personal connection The success of vaccines means that we don t see a lot of vaccinepreventable My friend s diseases husband anymore, had HPVrelated have to oropharyngeal remember they cancer are very and but we serious. I know For how example, devastating did it you can know be. that I am before definitely the measles vaccinating vaccine both my was son introduced, and daughter there against were 3-4 HPV so million I can give cases them a year, the best 48,000 people protection. were hospitalized and people died? Measles (Talk about is highly your own contagious story related and to not a vaccine-preventable just a little rash. disease.) 75

76 The Facts About Vaccines Vaccines give us the safe, proven power to protect ourselves, our families, and our patients from serious preventable diseases. Following the recommended schedule undoubtedly offers the best protection. 76

77 HPV VACCINE A Communication Case Study 77

78 HPV Infection Most American females and males will be infected at some point in their lives with at least one type Current estimate is 79 million 14 million new infections yearly Common in teens and early 20 s Most people will never know they have been infected Reprinted with permission from: & Jemal et al. J Natl Cancer Inst 2013;105:

79 HPV Vaccine Recommendations Age Routine vaccination at age 11 or 12 years, but can start at age 9 Vaccination recommended through age 26 for females age 21 for males (not previously vaccinated) Vaccination recommended for men through age 26 who have sex with men (MSM) or are immunocompromised (including persons HIV-infected) Dosing 2 shots administered six to twelve months apart 3 shots if started after 15 th birthday or with an immunocompromising condition 79

80 Top 5 Reasons for NOT Vaccinating Adolescents with HPV Vaccine (National Immunization Survey-Teen, US, 2013) 80

81 Make an Effective, Convincing Recommendation Same way: Recommend HPV vaccination the same way you recommend Tdap & meningococcal vaccines Same day: Recommend HPV vaccine today Recommend HPV vaccination the same day you recommend Tdap & meningococcal vaccines Your child needs 3 vaccines today: Tdap, HPV and meningococcal 81

82 82 Impact of Recommendation Quality Vaccine initiation rates: 20%-30% if no recommendation given or presented as optional 50% if low-quality recommendation 70-90% if a high-quality recommendation given Recommend same way, same day Opel Pediatrics 2013, Brewer Pediatrics 2016, Gilkey, et al., 2015

83 Optional versus High Quality Recommendations Optional: Have you thought about what shots you d like to get today? May unintentionally imply vaccination is not important, not recommended or few people receive it 20-30% vaccination rate in studies of both childhood and adolescent vaccines High quality: We have some shots to do today Implies vaccination is important and most people receive 70-90% vaccination rate in studies of both childhood and adolescent vaccines If a parent or patient hesitates, particularly for HPV vaccination: Our team is dedicated to cancer prevention I m sure the nurse (or doctor) will want to address your concerns. 83

84 Get Your Whole Team Involved in HPV Immunization and Communication 1. Recruit your whole office staff in the plan 2. Everyone who has patient contact, not just providers, gets educated about HPV vaccination and IS ON THE SAME PAGE (including front office staff) 3. Be sure that each office staff group knows their role in immunization and communication 4. Have everyone encourage questions; interpret them as natural caution, not refusal 5. Systematically arrange for the next dose 84

85 How to Handle Resistance: Step 1 Ask parents to share their concerns Example: So you seem to have concerns about the HPV vaccine. Well, that s perfectly understandable I ve had a number of questions about this one. Would you mind please sharing what your particular concerns are? (Note: non-threatening) Well, I ve heard that it s a vaccine to prevent a disease that s transmitted by having sex, and she is a loooong way from having sex. 85

86 How to Handle Resistance: Step 2 Reflect, Summarize, Ask, Advise Reflect back what the parent is saying to be sure you understand (showing empathy) Then summarize what has been heard before proceeding, again with permission, to make a recommendation For Example: So I hear that you re concerned that she s too young for the HPV vaccine because HPV is transmitted by sexual activity. Well, I completely get that she is only 11 after all. I ve thought a lot about this. Is it okay if I go over how I ve come to think about this vaccine? 86

87 How to Handle Resistance: Step 3 The crucial step Example: What NOT to say: Well, data shows that many adolescents will be having sex by middle school, and if you re worried about her having sex, studies have shown that it won t increase the likelihood of her having sex. Avoid using statistics like a battering ram in an emotional discussion 87

88 How to Handle Resistance: Step 3 The crucial step Example: What to say: I used to think of this vaccine as something to prevent a sexually transmitted disease, but realized it s really about preventing cancer. Almost everyone gets this virus, so I think it s important for every adolescent to receive before they re exposed to it. Instead of arguing, move the conversation back to what s really important: cancer prevention 88

89 How to Handle Resistance: Step 4 Make a personalized recommendation Example: If she were my daughter I would not hesitate to recommend this vaccine for her and most of my patients are getting the vaccine. Having said that, this is a decision that only you and your daughter can make. What do you think? 89

90 Motivational Interviewing (MI) MI Techniques Your next patient is a 12 year old boy who you haven t seen in a few years, in for a well visit and to get some forms signed You finish the visit and offer a presumptive recommendation for the HPV vaccine Not so fast His mother seems a little uncomfortable. Um, well, I d rather not do that HPV vaccine. I ve heard some bad things about it. 90

91 MI Techniques Ruler You are a little surprised, since you ve known this family for many years, and this child has received all of his recommended vaccines to now. To find out more you say, Example I see. So on a scale of 1 to 10, with 1 never getting the vaccine and 10 definitely getting it today, where are you at? (ruler) About a 3 OK can you tell me more about why you are a 3 instead of a 1? 91

92 Technique Open Ended Questions Well, I definitely don t want my son to ever have cancer, so I m open to the idea of the vaccine, but I m just scared it s not safe Example: Would you mind telling me what safety issues you are worried about? (openended question) Well, I ve heard that this is really just a vaccine for girls and that some children that get the shot can die from it. I know it s probably not true, but it just makes me worry. 92

93 Complications of HPV Infection The annual number of HPV-positive oropharyngeal cancers was expected to surpass the annual number of cervical cancers by the year This has already happened (2018) Photo from picstopin.com 93 This is no longer just a women s healthcare issue!!!

94 Techniques Affirmation and Permission You reflect back the concern to be sure you understand and summarize what has been heard before proceeding, again with permission, to make a recommendation. Example: Well, I can see why that information would scare you that would scare me too! (affirmation) This question of dying from the vaccine has come up for me before from other patients, and I ve looked into where it came from. Would you mind if I went over what I found out, and why I think this is such an important vaccine? (permission) 94

95 Techniques After getting permission, proceed with your response. Examples: To address you specific concern, it turns out people started rumors about this vaccine on the Internet, and those rumors spread. There is no truth to them. In fact, this is one of the safest vaccines we have, and it s been very well studied. This vaccine prevents several types of cancer in both men and women, and it works really well. I ve given it to my own children, and I think it s a really important vaccine. That said, this is a decision only you can make. (autonomy) 95

96 HPV Vaccine Side Effects? HPV vaccines have been studied extensively There are no studies showing serious safety concerns Common, mild adverse events reported include: pain in the arm (at the injection site) fever dizziness nausea Disclaimer: In general, some preteens and teens might feel faint after getting the HPV vaccine or any shot; so they should sit or lie down when they get a shot and stay like that for about 15 minutes to prevent any injury that could happen while fainting Fever photo from Microsoft clip art Sore arm photo from www2a.cdc.gov Nausea photo from genengnews.com Dizzy photo from 96

97 A Few Last Questions on HPV to Consider Do you routinely recommend delaying vaccination for rotavirus, DTaP, HIB, Pneumococcal and/or MMR until the child is actively & undeniably at risk for exposure? How many vaccines in your office are you not sure what recommendation your colleagues are making? Are preadolescents, adolescents and parents truly informed about HPV related disease? Are they getting their information from the best possible sources to decide (i.e. informed consent) on HPV vaccine? Does just say No work for sex as it does for drugs regardless of age? Honestly, could a vaccine be marketed as an aphrodisiac? Courtesy of Dr. David C Fredenburg 97

98 Avoid missed opportunities Review immunization records at every visit Acute/well child visits, dental visits, sports/camp physicals HPV vaccine is safely given with the other recommended adolescent vaccines Best recommendation is one that bundles all indicated adolescent vaccines Determine what works best for your practice Have a well-coordinated strategy Schedule the next HPV vaccine visit before patients leave the office or clinic Utilize reminder/recall strategies to ensure return for remaining doses photo from 98

99 Conclusions about HPV Vaccination Welcome questions from teens and their parents Educate that almost everyone gets HPV infection MUST EMPHASIZE THAT HPV IS NOT JUST FOR 99

100 Conclusions about HPV Vaccination Give parents strong recommendations & concrete reasons for HPV vaccine when their children are 11 or 12 years old Inform parents that HPV causes a variety of cancers in & Remind parents that HPV vaccine is for cancer prevention Listen carefully to parents and patients concerns So thankful to be here with you today! 100

101 Clinicians Must Set a Positive Example to Promote Vaccine Confidence Get your yearly influenza vaccines and timely Tdap boosters Comply with all vaccine recommendations for you & your children Build public trust & confidence by positively promoting vaccinations Encourage questions and intelligent discussion amongst those who lack vaccine confidence 101

102 Conclusions Thimerosol is not in children s vaccines Having you, your families and your patients vaccinated builds confidence and trust Autism has never been linked to vaccines Not vaccinating permits dangerous diseases to re-emerge/proliferate Keep addressing parents /patients concerns to make vaccines even more effective Someday perhaps measles, mumps, pertussis and other dangerous vaccine preventable diseases will be eradicated through vaccination and education 102

103 RESOURCES 103

104 6 Reasons Why Following the Recommended Schedule is Best List found at CDC Ultimate Babyproofing Website: Printable version: 104

105 Vaccine Confidence Resources For Parents Children s Hospital of Philadelphia (CHOP), Vaccine Education Center, Voices for Vaccines Every Child By Two, Vaccinate Your Family, Boost Oregon, Parent s Guide to Vaccines, For Providers Logical Fallacies and Vaccines: What You Should Know, Children s Hospital of Philadelphia (CHOP), Spring 2018 Let s Talk Vaccines: A Guide to Conversations About Immunization, Immunity Community Talking to Vaccine-Hesitant Loved Ones with Compassion and Confidence, Voices for Vaccines Clear Answers and Smart Advice About Your Baby s Shots, Immunization Action Coalition, State of the ImmUnion, Vaccinate Your Family/Every Child by Two (ECBT) Infant Immunization FAQs, Centers for Disease Control and Prevention (CDC) Vaccine Ingredients: What You Should Know, CHOP, 2016 Too Many Vaccines: What You Should Know, CHOP,

106 Voices for Vaccines Toolkit 106 Wonderful resource giving practical tips on how to talk to vaccine-hesitant loved ones Understanding why they lack vaccine confidence Respectful conversations geared to their concerns 106

107 Stories are important

108 New HPV Materials from National HPV Roundtable 108

109 Take away messages The majority of people vaccinate on the recommended immunization schedule. Following the recommended immunization schedule offers the best protection for you and your family. 109

110 Questions? Rebecca Vanucci Immunization Outreach Coordinator Everett Lamm, MD, FAAP Chief Medical Officer