Vaccine Hesitancy and Refusal: Addressing Concerns and Promoting High Immunization Rates Ailis Clyne, MD, MPH, FAAP Medical Director, Div CFHE Rhode Island Department of Health Importance of Vaccines The current routine childhood immunization schedule is estimated to: – Prevent 42,000 deaths – Prevent 20 million cases of disease – Save $14 billion in direct medical costs Per US birth cohort Zhou F, Shefer A, Wenger J, et al., Economic evaluation of the routine childhood immunization program in the United States, 2009. Pediatrics. 2014; 133(4):577–585 The success of vaccines in reducing disease-associated mortality is second only to the introduction of safe drinking water Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg2010;8(5):336–41 Impact of HPV Vaccination Currently 26 million girls <13 yo in the US; If none of these girls are vaccinated then: 168,400 will develop cervical cancer and 54,100 will die from it Vaccinating 30% would prevent 45,500 of these cases and 14,600 deaths Vaccinating 80% would prevent 98,800 cases and 31,700 deaths RI Immunization Rates • • • • • Rhode Island childhood and adolescent immunization rates are among the highest in the country Exemptions for school mandated vaccines are quite low: 1.1% for Kindergarten and 0.6% for 7th grade (2012-2013) Influenza Vaccine: Rhode Island had the highest coverage rate in the nation for the influenza vaccination among children 6 months through 17 years of age with a 74.5% during the 2013-2014 influenza season. Children: Rhode Island had the highest coverage rate in the nation for the 4:3:1:3:3:1:4 series (4DTaP, 3 Polio, 1MMR, 3 HepB, 3 Hib, 1 Varicella, 4 PCV) among children 19-35 months of age with an 82.1% in 2013. Adolescents: Rhode Island had the highest coverage rates in the nation for the 1+ Tdap vaccine (95.5%) and 3+ HPV vaccine for females (56.5%) and males (43.2%) among adolescents 13- 17 years of age in 2013. RI Immunization Rates Vaccine Hesitancy Categorizing Vaccine Hesitancy • Gust et. al.: 5 categories of VHP based on perceived necessity and safety – Immunization Advocates (33%) – Go Along to Get Alongs (26%) – Health Advocates (25%) – Fence Sitters (13%) – Worrieds (3%) • Leask et. al.: categories of all parents – Unquestioning Acceptor – Cautious Acceptor – Hesitant – Late/Selective – Refuser Assessing Vaccine Hesitancy Parent Attitudes about Childhood Vaccines Survey Opel DJ, Mangione-Smith R, Taylor JA, et al. Development of a survey to identify vaccine hesitant parents: the Parent Attitudes about Childhood Vaccines survey. Hum Vaccin. 2011; 7(4):419–425 Factors Influencing Vaccine Hesitancy • • • Racial/ethnic disparities Lower income level associated with reporting not having enough vaccine information Refusal of all vaccines more common among college educated parents. • Immediate or short term effects: pain, fever, redness, swelling • Long term effects concerns: autism, GBS • Omission bias: prefer the consequences of doing nothing to the consequences of doing something • Number of vaccines: pain, side effects when receiving multiple vaccines, immunologic overload • Lack of personal experience with the disease leads to an underestimation of the severity of the disease Charitha Gowda and Amanda F DempseyHuman Vaccines & Immunotherapeutics 9:8, 1755–1762; August 2013F Dempsey2, • Vaccine refusers- less emphasis on providers’ recommendations when making healthcare decisions • School mandated vaccine policies significantly increase vaccine coverage levels • Media: tailored messaging based on level of vaccine hesitance, finding a celebrity vaccine champion Images and Social Media Vaccine Hesitancy and Refusal: Common Themes • • • • • • Safety / “new” Perceived associations with specific conditions Unnecessary Parental autonomy to make vaccine decisions Efficacy Unnatural Non-standard vaccine schedules Non-standard vaccine schedules • • • Pediatrics April 2015 • • • Survey of 534 of pediatricians and family physicians in 2012 87%-parents were putting their children at risk for disease 84%-alternative schedules are more painful for children 82%-agreeing to requests for nonstandard schedules builds trust with families 80%-parents might leave the practice if a non-standard schedule request is declined Providers agreed to spread out vaccines: – – • Often/always 37% Sometimes 37% Providers discharge families from the practice – – – Often/always 2% Sometimes 4% Rarely 12% Addressing vaccine hesitancy and refusal Vaccine refusal not only increases the individual risk of disease but also increases the risk for the whole community Message Framing Pediatrics September 2014 What’s Recommended? • Understanding parental concerns • Establish honest dialogue • Acknowledge that vaccines may be associated with adverse events and balance that against disease risk • Address specific vaccine concerns • Provide other information resources • Ensure ongoing communication • The AAP Committee on Bioethics does not recommend discontinuing care for families who refuse or delay immunization What Works? Vaccine 2013 • Literature review July-September 2012 including 30 studies 1. Passage of state laws 2. State and school level implementation of laws 3. Parent-centered information or education --> brochures, pamphlets, posters, parent meeting, radio, power point, web-based decision aid 1. "The introduction of philosophical/personal exemptions in states consistently showed an increase in non-medical exemption rates.“ 2. "...decreased exemption rates with early and frequent notification of parents for school entry immunization requirements“ 3. "Our systematic review did not reveal any convincing evidence on effective interventions to address parental vaccine hesitancy and refusal" Legal Basis For School Immunization Requirements • 1809: Massachusetts passed a law requiring small pox vaccine to prevent and control frequent smallpox outbreaks that had substantial health and economic consequences • 1905: Jacobson v. Massachusetts US Supreme Court endorsed the rights of states to pass and enforce compulsory vaccination laws. • 1922: Zucht v. King US Supreme court find school immunization requirements to be constitutional Vaccine Exemptions Communication Strategies Effective messages in vaccine promotion AUTHORS: Brendan Nyhan, PhD,a Jason Reifler, PhD,b Sean Richey, PhD,c and Gary L. Freed, MD, MPHd,e, Pediatrics 2014 •Phone survey of 1759 US parents •Survey of attitudes towards vaccines •Randomly assigned to 1 of 4 pro-vaccine messages or control 1. Correcting misinformation-MMR vaccine and autism 2. Presenting information on disease risks-symptoms of MMR, adverse events after vaccine-MMR VIS 3. Using dramatic narratives-CDC narrative of mother's recounting of infant son with measles hospitalization 4. Displaying visuals-pictures of a child with each disease •Post message survey • vaccines and autism • vaccines and side effects • likelihood of giving MMR vaccine to a future child Communication Strategies • None of the 4 interventions increased intent to vaccinate among parents who are the least favorable towards vaccines • Corrective information from the CDC website successfully corrected misperceptions about MMR causing autism but also reduced vaccination intent among parents with least favorable vaccine attitudes • Both the dramatic narrative and images of sick children increased misperceptions of MMR vaccine • Importance of testing health messages for effectiveness before dissemination Communication Strategies Presumptive: (74% of providers) “Well, we have to do some shots.” “So, we’ll do 3 shots and the drink, is this okay?” 26% of parents resisted vaccines Participatory: (26% of providers) “Are we going to do shots today?” “What do you want to do about shots?” “You’re still declining shots?” 83% of parents resisted vaccines Provider does not pursue: “Okay” “We could split them up” “We could do them when you come back in 2 months” Provider pursues vaccine recommendation: (50%) “He really needs these shots” “Whooping cough can be a killer in the kid under 1” 47% of parents who were resistant agree to vaccines Pediatrics 2013 AUTHORS: Douglas J. Opel, MD, MPH, John Heritage, PhD, James A. Taylor, MD, Rita Mangione-Smith, MD, MPH, Halle Showalter Salas, MPhil, Victoria DeVere, BS,Chuan Zhou, PhD, and Jeffrey D. Robinson, PhD Vaccine Information Resources Vaccine Information Resources http://www.cdc.gov/vaccines/ http://www.immunize.org/ http://vec.chop.edu/service/vaccine-education-center/home.html https://www.iom.edu/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety.aspx Measles Vaccine Resource HPV Vaccine Resources http://www.cdc.gov/vaccines/who/ teens/for-hcp-tipsheet-hpv.pdf HPV Vaccine Resources Ailis Clyne MD, MPH Medical Director Division of Community, Family Health, and Equity 401.222.5928 Ailis.clyne@health.ri.gov www.health.ri.gov