Not a shot in the dark:
Restoring confidence in vaccines
Shelley Deeks, Medical Director
Tara Harris, Nurse Consultant
Jill Fediurek, Manager
Immunization and Vaccine Preventable Diseases
Learning objectives
1. To list the factors that influence vaccine hesitancy among
parents, the general public and health professionals.
2. To describe approaches to engage the vaccine hesitant and
empower immunizers.
3. Build immunization communication skills and confidence
through use of the A-S-K® approach, a practical tool for
addressing concerns about immunization.
4. To have fun through our exercise!
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How many lives are saved by
immunization?
2-3 million lives
per year
6-8000 lives
per day
2-300 lives
per hour
4-6 lives
per minute
1 life every 10
seconds
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Yet our success is threatened by
• Well organized consumer groups
• Devastating stories
• Popularity of alternative health care
• Increased competition in media
• Rapid communication technologies and demographic appeal
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Temporal trends in Ontario
MMR/measles exemptions: 7-year-olds
2.50
Proportion of students (%)
2.00
2002/03
2003/04
2004/05
1.50
2005/06
2006/07
2007/08
1.00
2008/09
2009/10
0.50
2010/11
2011/12
0.00
Medical Exemptions
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Religious/Conscientious
Exemptions
Total Exemptions
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Bottom Line: it’s a conundrum for parents:
whom to believe?
Providers
Individual
Pro-vaccine
Media
Anti-vaccine
Internet
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Friends
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UNDERSTANDING VACCINE
HESITANCY
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Vaccine acceptance
Vaccine attitudes
Refuse
• a continuum ranging from total
acceptance to complete refusal
Accept
Vaccine hesitant individuals
• heterogeneous
• middle of the continuum
• may refuse some but agree to
others, may delay vaccines or may
accept vaccines but are
concerned
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Hesitant
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Definitions
• Vaccine hesitancy
• A behaviour, influenced by a number of factors including issues of confidence,
complacency, and convenience
• Vaccination Confidence
• Trust in the effectiveness and safety of the vaccine and the system that delivers
them
• Vaccine Complacency
• Do not perceive the need for the vaccine
• Perceived risks of VPDs are low and vaccination not deemed necessary
preventive action
• Vaccination Convenience
• Access, affordable, appealing
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Perspective of Risk: Personal not
Science/Evidence Based
“What does it mean for
me and my family. What
should I do about it?”
Even when one believes vaccines
are important they may still have
concerns
Complacency
Benin et al Pediatrics 2006;117:1532-41
Freed et al Pediatrics 2010;125:654-659
Kwok R. The real issues in vaccine safety. Nature
2011;473:436-438
Larsen et al. Addressing the vaccine confidence gap.
Lancet 2011; 378(9790):526-35
WHO Euro 2011
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Confidence
Convenience
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Vaccine hesitancy is not new
• The Dangers of Cow Pock, by caricaturist James Gilray in 1802
Anti Vaccination League and Anti-Compulsory Vaccination League formed in UK in
1850s in response to the mandatory laws
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Published by The London Society
for the Abolition of Compulsory
Vaccination. Late 1800s
The Historical Medical Library of The College
of Physicians of Philadelphia, 1892
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Understanding Beliefs
Anchoring belief
Starting from a known value
(anchor) and judge probability of
future event by what occurred in
past
Association
An event judged as frequent or
likely to occur if it can be easily
imagined or recalled
Co-incidence factor:
After this, therefore because of
this
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Examples:
Parent
• too many vaccines stress immune
system
• “see” AEFIs but not aware of VPD
• MMR and autism
Health care provider
• if “see” elderly patients with PHN,
more likely to promote zoster
vaccine
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Understanding Behaviour
Omission
• Actions more harmful
than inactions
• Reluctance to be
immunized - wait and
see…
Public
• New vaccine: wait to see if
there is a problem and if
safe. Wait to immunize:
“my baby too small now”
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Factors Associated with increased Influenza vaccine
uptake among HCW in Hospitals: a meta-analysis
• Knowing that the vaccine
is effective
• RR 2.2 (95% CI 1.9-2.5)
• Being willing to prevent
influenza transmission
• RR 2.3 (95% CI 2.0-2.7)
• Believing that influenza
prevention is important
• RR 3.6 (95% CI 2.9-4.6)
• Having a family that is
usually vaccinated
• RR 2.3 (95% CI 1.6-3.3)
• Believing that influenza is
highly contagious
• RR 2.3 (95% CI 1.7-3.1)
Riphagen-Dalhuisen J, Gefenalte G, Hak E Occup Environ Med 2012;69:230-235
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How can we shape beliefs?
Engage the public
• Build trust
• Ensure sustained support for immunization
• Build resiliency for crisis
• Learn about public concerns
• Be prepared to address them
• Learn about public’s strengths and skills
• And use this to support immunization programs
• Be patient
• It is likely that evidence is not enough (e.g. exercise / smoking)
Peterson P, Larson H. The role of publics in the introduction of new vaccines. Health Policy and Planning 2012;27:ii77-ii79
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Traditional
Assumptions:
• Parents make decisions through
a comparison of individual risk
• Parental concern about
vaccination is due to a
miscalculation of risk
• A policy of providing more risk
statistics is the best response to
the controversy
But little evidence it works!
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What influences responses to information on
risk?
• Extent to which the source of the information is trusted
• Relevance of the information for life and decision making
• Relation to other perceived risks
• Fit with previous knowledge and experience
• The difficulty and importance of the choices
and decisions
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Where do Canadian parents go for information
If you were looking for the most reliable and trustworthy information on vaccines,
where would you look or who would you talk to?
68%
Physician
Internet
Public health nurse
Local PHA
Family member/friend
Other HCW
CLSC
Health Canada
Pharmacists
Government
Research studies
Other
DK/NR
27%
13%
7%
5%
5%
5%
4%
3%
2%
2%
10%
2%
0
10
N=1,737
20
30
40
50
60
70
80
Available at: http://resources.cpha.ca/immunize.ca/data/1792e.pdf
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Communication
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Communication: Make better use of evidence
• Disease data
• Perception of risks
• Vaccine benefits
• Frame the message
• Vaccines 99% safe versus 1% risk of side effects
• Tell compelling stories
• Personalize the message
Levin IP et al. Organ Behav Hum Decis Process 1998;76:149–188
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Balancing disease and vaccine
Disease:
burden and
complications
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Vaccine:
associated risk
and benefit
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Adverse effects of measles and measles vaccine
Measles
Measles vaccine
• Pneumonia: 1 in 20
• Up to 5% malaise and fever
• Hospital admission: 1 in 100 • Convulsions: 1 in 3,500
• Convulsions: 1 in 200
• Meningitis / encephalitis: 1
in 1,000,000
• Meningitis / encephalitis: 1
in 1,000
• Anaphylaxis – 1 per million
• SSPE: 1 in 100,000
• SSPE - not linked
• Death: 1 in 5,000
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Visuals
may
help
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http://www.ncirs.edu.au/immunisation/education/mmr-decision/measles.php
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GBS: Influenza versus influenza
vaccine
PublicHealthOntario.ca
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Is there a perfect vaccine?
Vaccines should cause no
adverse reactions and
completely prevent the infection
that they target
Current technology does not
allow for such perfection.
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NO
Key is to minimize
adverse events and
ensure safe use of
vaccines
Adverse events are
monitored
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BUT: they are getting safer all the time
• Vaccines given to today’s children are safer
than the vaccines given to their parents
• Oral polio vaccine replaced with inactivated polio
vaccine in 1998
• Whole cell pertussis vaccine replaced with
acellular pertussis vaccine in 1997/8
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Available at http://www.phac-aspc.gc.ca/publicat/cig-gci/p01-02-eng.php
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What do Canadian parents think?
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Available at: http://resources.cpha.ca/immunize.ca/data/1792e.pdf
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PHO’s 2012 Vaccine Safety Report:
“Framing the Message”
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Available http://www.publichealthontario.ca/en/About/Newsroom/Pages/Public-Health-Ontario-releases-Annual-Report-on-Vaccine-Safety-in-Ontario.aspx
Embrace the Legacy
Smallpox changed the course of history
• 1/3 of people who
contracted smallpox died;
survivors were left
disfigured, blinded
• 300 million people died
from smallpox during the
20th Century
• Smallpox caused 90% of the
deaths of indigenous
peoples during colonization
Vaccination made it history
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Available at http://www.nlm.nih.gov/exhibition/smallpox/sp_obstacles.html
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Immunization “disappear-o-gram”
Reported cases and incidence of invasive Haemophilus influenza
type b, and year of vaccine introduction
Available at http://www.phac-aspc.gc.ca/im/vpd-mev/hib-eng.php
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Compelling Stories
What happens when immunization is disrupted?
“Syria has become a cauldron of once-rare
infectious diseases, with hundreds of cases of
measles each month and outbreaks of typhoid,
hepatitis, and dysentery. … and now polio is back.
Since May, Syrian doctors and international public
health agencies have documented more than
ninety cases of polio..”*
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From: Syria’s Polio Epidemic: The Suppressed Truth, by Anne Sparrow. Feb 20, 2014
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Compelling stories: Tetanus
Alijah was hospitalised with
“WAKE UP CALL”
tetanus late last year; something
he should have been immunised
against, something Williams and
his wife Linda decided not to do. It
was a painful lesson.
"When it came to my kid's health, I
let the hippy win. I should have let
the science win."
Available at http://www.stuff.co.nz/national/health/8199964/We-were-hippies-about-it
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Compelling stories: Meningococcal disease
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Compelling
Stories:
Influenza
Amanda, died at age 4½ yrs
from influenza
Lucio, died at age 8 yrs
from influenza complications
Breanne, died at age 15 mos
from influenza complications
Alana, died at age 5½ yrs
from influenza
Barry, a veteran fire-fighter,
died at age 44 yrs from
influenza
Source: Families Fighting Flu
Acknowledgements
• Natasha Crowcroft, PHO
• Noni MacDonald, Dalhousie
• Sarah Wilson, PHO
• Tara Harris, PHO
• Steven Janovsky, PHO
• Jane Lamothe, PHO
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Immunization
communication strategies
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Immunization competencies for health
professionals: Essential immunization
practices
6. Communication
Communicate effectively
about immunization, as
relevant to the practice
setting(s)
13. Immunization issues
Address immunization
issues using an evidencebased approach
• Assess client knowledge, attitudes and beliefs
• Deliver clear, concise messages about the risks
and benefits of vaccines
• Guide clients to credible sources of information
• Describe factors that lead to skepticism about
immunization
• Address misperceptions about vaccines using an
evidence-based approach
Source: Public Health Agency of Canada (PHAC), 2008. Available from: http://www.phac-aspc.gc.ca/im/pdf/ichp-cips-eng.pdf
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Immunization communication
resources for health professionals
• Resource documents – Canadian Pediatric Society, Immunize Canada
• Tools – A-S-K® approach, C.A.S.E. approach
• Visual aids - infographics, decision aids
• Personal stories
Sources:
1. Pfizer. Available from: http://www.vaccines.com/_downloads/PDF/infographic_whatsmorelikely.pdf
2. Special Broadcasting Service. Jabbed: Love, Fear & Vaccines. Available from: http://www.sbs.com.au/shows/jabbed#
3. Macdonald NE., Finlay, JC. Working with vaccine-hesitant parents. Paediatrics & Child Health 2013 May; 18(5):265. Available from:
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http://www.cps.ca/documents/position/working-with-vaccine-hesitant-parents
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Source: S. Harris. Science Cartoons Plus. http://www.sciencecartoonsplus.com/index.php
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Communication strategies - common elements of a
successful dialogue
• Take time to listen
• Solicit and welcome questions
• Keep the conversation going
• Acknowledge risks and benefits
• Tailor the approach – one size does not fit all
• Have both science and stories available
Sources:
1. Centers for Disease Control and Prevention. Provider Resources for Vaccine Conversations with Parents. Available from:
http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/conv-materials.html
2. Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: A framework for health
professionals. BMC Pediatrics. 2012;12(1):154.
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The A-S-K Approach© for effective
immunization communication
• A tool for health professionals to address immunization
questions and concerns
• Provides a framework for the client interaction that consists
of 3 key steps
Acknowledge your client’s concerns
Steer the conversation
Knowledge - Know the facts well!
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A: Acknowledge your client’s concerns
• Acknowledge
• “I hear what you’re saying. That’s a common question I get.”
• “That’s a good question. I’m glad you asked it”
• “It’s great that you’ve done some research. It’s good to ask questions.”
• Clarify to understand your client’s needs
• “Tell me more about what you’ve heard”
• “If I understand you correctly, what you’re asking is…”
• “So your concern is that…” / “I’m hearing you say that…”
• Assess level of commitment to immunization
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Assess the level of commitment to
immunization: Know your audience
Believers
Relaxed
• Highest level of commitment to immunization
• Low information needs
• Follow routine schedule
Low
• High commitment to immunization
• Low to moderate information needs
Perception
of risk
Cautious
Unconvinced /
conscientious
objector
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• Low to moderate commitment to immunization
• High information needs
• Spend time!
• No commitment to immunization
• Be cautious of lengthy debate, close discussion skillfully
• Leave door open to future discussion
High
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S: Steer the conversation
• Steer the conversation based on assessment of the concerns and
level of commitment of the client
• Refute the myths & misinformation (be specific)
• “Actually that’s a common myth…”
• “Unfortunately the internet can have inaccurate information depending on
where you look.”
• Continue the conversation
Closing ideas for conscientious objectors..
• Discuss repercussions of vaccine refusal, leave the door open
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K: Knowledge - Know the facts well!
• Provide further knowledge, tailored client's needs
• Nurse ↔ client knowledge transfer (Give-listen-clarify as needed)
• Always ask your client if they would like further reading materials
• “Can I send you more information by email?”
• Provide your recommendation
• “I strongly recommend all immunizations.”
• To close, reinforce discussion with a benefit statement
• “Immunizations have saved many lives.”
• “Vaccines are safe and effective.”
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A-S-K© approach resources
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Role play exercise
Applying the A-S-K© Approach
Review the setting
(magenta) card
Respond using the ASK©
Desk Reference and
Immunization
Communication Tool
Chooses 4 cards (1 of each
colour)
Health
professional
Client
Problem solve with
observer what the client
type, communication
topic, and source of
misinformation
Share only the setting
(magenta) card with the
health professional &
observer
Use the “conversation
starter” (yellow card) to begin
the interaction
Role play using the client type
(yellow), communication
topic (purple) and source of
misinformation (green) cards
Observer
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→ When role play is complete, switch
roles, select new cards and repeat the
process so that everyone has a chance to
be the health professional (5 min/role
play)
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Applying the A-S-K© Approach
Discussion questions
• Discuss at your table:
• How did you feel as the health professional in these role-play scenarios?
How did you feel as the client?
• In the future, would you use the A-S-K© approach?
• What communication strategies have worked for you in the past?
• What are some immunization communication resources you use?
• At your table choose one thing to report back to the larger
group that you will use in your practice
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Acknowledgements
• British Columbia Immunization
Committee Professional Education
Working Group (PEWG)
• Shaila Jiwa, BCCDC
IVPD @ PHO team
• Jill Fediurek
• Shelley Deeks
• Margaret McIntyre
• Michelle Uy
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Immunization communication
resources for health professionals
• Immunize Canada - Guide to immunization information on the internet
http://resources.cpha.ca/immunize.ca/data/0288e.pdf
• Immunize BC - A-S-K Approach, Immunization Communication Tool, personal
stories
www.immunizebc.ca
• CDC – Provider resources for conversations with parents
http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/index.html
• Immunization Action Coalition – Talking with parents resource list
http://www.immunize.org/concerns/comm_talk.asp
• Top Ten Immunization infographics
http://teamvaccine.com/2013/08/16/top-10-vaccine-infographics/
• Personal stories
• Parents of Kids with Infectious Diseases www.pkids.org
• Meningitis Research Foundation www.meningitis.org
• Voices for Vaccines www.voicesforvaccines.org
• Shot by Shot www.shotbyshot.org
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