Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007.
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Transcript of Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007.
Communicating with parents, providers, and the media
Alan R. Hinman, MD, MPH
October 16-17, 2007
Outline of presentation
• General considerations of vaccine use• Risk assessment, management, and
communication• Parent attitudes, provider practices• Role of the media• What can we do?
Modern vaccines
• Modern vaccines are safe and effective• However, they are neither perfectly safe nor
perfectly effective
• Some persons who receive vaccine will have adverse event
• Some persons who receive vaccine will not be protected
Balancing benefits and risks
• Use of vaccine depends on balance of benefits and risks
• This balance may change over time– For example, OPV/IPV
National Research Council Definitions
• Risk assessment – use of the factual base to define the health effects of exposure of individuals or populations
• Risk management – weighing policy alternatives and selecting appropriate actions
Risk Communication
• Risk has technical and cultural components• Technical – hazard• Cultural – “outrage”
Risk = Hazard + Outrage
Source: Sandman 2002
Outrage FactorsLow High
Voluntary CoercedNatural IndustrialFamiliar ExoticNot memorable MemorableNot dreaded DreadedChronic CatastrophicKnowable UnknowableIndividual control Controlled by othersFair UnfairMorally irrelevant Morally relevantTrustworthy sourcesUntrustworthy sourcesResponsive process Unresponsive process
Features of postmodern society
• Distrust of science• Greater attention to risk• Readiness to refer to the judiciary• Better access to real-time information• Physicians as knowledge managers rather
than knowledge repositories
Source: Muir Gray – Lancet 1999;354:1550-1553
Postmodernism – Public Health
• Scientists must take care not to treat fear and reservation as ignorance and then try to destroy them with a blunt “rational” instrument.
Source: Pattison – BMJ 2001;323:838-840
Maturity
Incidence
Disease
VaccineCoverage
AdverseEvents
Prevaccine IncreasingCoverage
1
Loss ofConfidence
Outbreak
VaccinationsStopped
Eradication
Eradication
2 3 4 5
Resumption of Confidence
Evolution of Immunization Program and Prominence of Vaccine Safety
Parents’ beliefs about immunizations - 1 • Imm one of safest medicines 78%• Imm getting better & better 89%• Imm always proven safe before use 71%• I have access to information 92%• Imm requirements protect my child 84%• Parents should be allowed to send
unimmunized kids to school 14%
Parents’ beliefs about immunizations - 2• Kids get more shots than are good
for them 23%• Immune system could be weakened
by too many immunizations 25%
Source: Gellin et al, Peds 2000;106:1097-1102
Reasons for lack of supportfor immunizations
• Ignorance• Fear• Contraindication• Religion• Philosophy• “Informed” opposition
Unvaccinated vs undervaccinatedSmith. Peds. 2004;114:187-195
• Unvaccinated more likely to be white, have married mother with college degree, live in house with income 75,000, and have parents with concerns about vaccine safety
• Undervaccinated more likely to be black, have unmarried mother without college degree, live in house near poverty level, and live in a central city
Parental concerns and behavior after immunization
Gust. Am J Prev Med 2006;31:32-35
• Parents who sought medical attention for a child due to AEFI compared to those who did not
• Those who sought medical attention more likely to be white, >35, believe that immunizations cause minor side effects, report unwanted yet required immunization, not want a new baby to be fully immunized, report concerns about vaccine safety, believe that immunizations are dangerous, have a child missing 2+ doses of DTP, MMR or hep B
Suspicions about the safety of vaccinesCampion. NEJM 2002;347:1474-1475
“Objective data are not likely to put an end to the controversy. Strongly held beliefs are difficult to change. We live in an era in which the public does not have a high degree of trust in the vaccine manufacturers, the government, or the medical establishment. Consumers have become highly sensitive about safety…
Suspicions about the safety of vaccinesCampion. NEJM 2002;347:1474-1475
Unsubstantiated accusations that a vaccine causes harm can have serious consequences
• Some people avoid vaccination• Costly legal action follows• Manufacturers associate vaccines with
adverse economic effects• Vaccines may be withdrawn from the market• It becomes harder to run vaccination
programs
Vaccine requirements2006-2007 school year
• Diphtheria 50• Tetanus 50• Polio 50• Measles 50• Rubella 50• Mumps 48• Pertussis 48• Hepatitis B 48
• 2d measles 45• Varicella 49• Hepatitis A 6
• Hib (DC) 50• Hib (Head Start)47
Exemptions to immunization requirements
2006-2007 school yearMedical 50 states
Religious 48 states
Philosophical 17 states
Frequency of exemptions2003-2004 school year
Type #rep High State#>1.0%
Med 2.6% IN 4
Rel 3.2% WY 4
Phil 3.6% WA 10
Children entering kindergarten with vaccination personal belief exemptions, 2006
California Dept of Health ServicesImmunization Branch
0 – 49
50 – 99
100 – 199
200 - 1102
Number PBEs
0.00 – 0.99
1.00 – 2.99
3.00 – 4.99
5.00 – 14.37
Percent PBEs
Opposition to immunization - 1
• <1% of entering students have exemptions– 7 states had >1%– Michigan had 2.3%
• 13 outbreaks of measles 1985-1994• Recent outbreaks of pertussis and rubella• 1970s outbreaks of polio• RPEs have 11-52x risk of measles
Opposition to immunization - 2
Pertussis incidence 10-100x higher
in countries where immunization
programs were compromised by
anti-vaccine movements
Source: Gangarosa et al, 1998
Opposition to immunization - 3
11/113 child deaths associated with “religion-motivated medical neglect”
1975-1995 due to VPD
– 7 measles
– 3 diphtheria
– 1 pertussis
Source: Asser and Swan, 1998
Pediatricians’ Communication with Every Dose of DTP/DTaP
• Discuss risks/benefits 53.6%• Distribute VIS 61.2• Document VIS 55.0• Document verbal consent 36.2• Obtain signature 72.4
Source: AAPNews, Feb 2003 p71
Antivaccination Web Sites - 1
• Identified 22 antivaccination web sites• Studied content and design attributes
Source: Wolfe et al JAMA 2002;287:3245-3248
Antivaccination Web Sites - 2
• 100% - vaccines cause idiopathic illness• 95% - vaccines erode immunity• 95% - adverse reactions underreported• 91% - vaccine policy motivated by profit• 81% - vaccines produce temporary imm.• 77% - mandatory vax violate civil liberties• 73% - diseases declined w/o vaccines• 50% - multiple vax increase risk
Types of misinformation found on websites critical of vaccines
• False conclusions from true statements• “Straw man” arguments• Hidden profit motivation• Appeals to emotions• Lies• Appeals to distrust of govt & industry
Source: T Anderson, IAC, 2003
Antivaccination activists on the world wide web
Davies. Arch Dis Child 2002;87:22-25
• Used 7 search engines on “vaccination”and “immunisation or immunization”
• 43% of sites using “vaccination” returned antivaccination sites vs 6% using “immunisation or immunization”
Antivaccination activists on the world wide web
Davies. Arch Dis Child 2002;87:22-25
Rhetorical appeals• Evidence of authority and scientific rigour• Emotive appeals• Evidence of conspiracy, search for truth• Explicit claims
Subtexts in anti-immunization articles
Leask. Aust N Z J Public Health 1998;22:17-26• Cover-up• Excavation of the facts• Unholy alliance for profit• Towards totalitarianism• Us and them• Poisons• Vaccines as the cause of idiopathic ills• Back to natures
Profit motive or altruism?
• “GlaxoSmithKline (GSK) is trying to get the hepatitis A vaccine made mandatory for children entering California schools…
• “…The company has made large campaign contributions, and much of the money has gone to Hispanic legislators, who have introduced a mandatory vaccine bill three times over the past three years.”
Source: Sacramento Bee, July 14, 2002
Profit motive or altruism?
• “Merck & Co. is helping bankroll efforts to pass state laws requiring girls as young as 11 or 12 to receive the drugmaker’s new vaccine against the sexually transmitted cervical cancer virus.”
Source: Associated Press, January 30, 2007
IOM Workshop on risk communication and vaccination
• Risk communication is a dynamic process• Goal should be informed decision-making• There is uncertainty about risk estimates -
honesty about this will contribute to trust
Source: Stoto et al, 1998
Institute of Medicine Report on MMR and Autism - 2001
“…the committee has concluded that the evidence favors rejection of the causal relationship at the population level between MMR vaccine and ASD…its conclusion does not exclude the possibility that MMR vaccine could contribute to ASD in a small number of children…”
Institute of Medicine Report on MMR and Autism - 2004
“The committee concludes that the body of epidemiological evidence favors rejection of a causal relationship between the MMR vaccine and autism...[and] between thimerosal-containing vaccines and autism...potential biological mechanisms for vaccine-induced autism...are theoretical only.
“...available funding for autism research [should] be channeled to the most promising areas.”
Themes for dealing with doubts
• Carpe diem• Be prepared• For advanced doubters, be very prepared• Appreciate the illogical
Source: Scheifele, 1997
Achieving / Maintaining Communication Credibility
• Respond quickly• Get the facts right, repeat them
consistently• Express empathy and caring, acknowledge
uncertainty• Provide competent spokespersons with
expertise• Provide honest, open responses even if
they are not positive• Follow through, do what we say we will
Multiple media / information sources
• Over 1,500 daily newspapers• Over 15,000 health, medical, and science-
related websites• Hundreds of consumer and professional
publications (e.g., magazines, newsletters)• A multitude of television networks, stations,
and programs• A host of radio networks and stations
Which means. . .• Lots of competition for media, provider, and
public attention• Competition for medical and health
recommendations • High potential for conflicting information and
advice• More is usually not better• Different interpretations are likely
Competing goals and conventions
Public Health• Thoughtful, considered,
and consistent approach to new developments, data, research
• Precisely accurate information and recommendations
• Quickly build (and/or retain) population adoption of a specific recommendation
• Frequent, high visibility stories that promote health and recommendations for safe/healthy living
• Media story = immediate behaviors by many
News Media• Ongoing need for things to be
“new” (new angles, new developments)
• Stories, information, and ideas that highlight a spectrum of healthy, risky, and dangerous things and perspectives
• Be unique / be different• Build/retain an audience• “Essentially” accurate
information – conveyed with interesting and colorful quotes
• Simple and often provocative headlines
Vaccine-related Communications: Challenging Media Conventions
• Length – journalists and editors try to retain the truthfulness of a story while condensing it.
• Media create and present “stories”– Good stories require conflict – and conflict
usually requires “victims,” “villians” and “heroes”
– Colorful quotes– “Balance” (e.g., stories generally need more
than one point of view)– Nuance and context are often lost in the
process• Headlines must grab attention
Things to Keep in Mind
• Reporters are not “court” reporters – They are not transcribing your comments– They paraphrase and can alter context– “Translation” and interpretation are viewed
as key roles• Reporters are not the only people involved in
the final story and its presentation– Editors play significant roles– Reporters don’t write the headlines
• Nuances and fine distinctions rarely translate
Mixed messages can easily arise. . .
• “It’s (really) important you get an influenza vaccination” vs. “You can wait until (December, January, February, etc.)”
• “Influenza is a potentially serious disease/illness” vs. “For the vast majority of people, influenza is an unpleasant but manageable illness.”
• “Everyone benefits from an influenza vaccination” vs. “People in the following groups (really) benefit from an influenza vaccination.”
• “It’s important you get vaccinated” vs. “It’s important you get your vaccination from (______________)”
Keys to Effective (Risk) Communication
• Credibility • Trust / Honesty• Mutual respect • Commitment • Expertise (including good quality
information)• Empathy• Recognition that individual decisions may
be based more on values than on evidence
Factors affecting vaccine acceptance(Ball, Peds 1998;101:453-458)
• Compression• Omission bias vs commission bias• Ambiguity aversion• Voluntary, controllable risks• Natural risks• Frightening or memorable risks• Availability• Freeloading• Bandwagoning• Altruism
6 common misconceptions about vaccination
• Diseases had already begun to disappear• Majority of people who get disease have been
vaccinated• “Hot lots” of vaccine have been associated
with more adverse events• Vaccines cause harmful side effects,
illnesses, and even death• VPD have been virtually eliminated from US• Multiple vaccinations at same time increase
risk of harmful side effects and can overload the immune system
Addressing parents’ concerns about childhood immunization:
A tutorial for PCP
• Levi. Peds 2007;120:18-26• CD-ROM based 45 minute tutorial• Significantly improved residents’ general
knowledge, knowledge of adverse events, and attitudes regarding immunization
• Will become available soon
Components of effective risk communication
Ball. Peds 1998;101:453-458• Communicate existing knowledge• Recognize factors influencing parental risk
perception• Acknowledge potential risk communication
pitfalls• Engage parents appropriately – decision-
making partnership with physician
AAP and parental refusal
• 79% of pediatricians have had >1 instances of parents refusing to allow child to be vaccinated
• ~10% of pediatricians report >10% of parents avoiding vaccines because of safety concerns
Responding to parental refusals of immunization of children
Peds. 1005:115:14281431
• 3 distinct issues– Do parents who withhold immunizations
risk harming children sufficiently that this is actionable medical neglect that should be reported to child protective services
– Do parental decisions put other individuals at risk of harm sufficient to justify public health intervention
– How should pediatrician respond to parents who refuse immunizations for their children
Responding to parental refusals of immunization of children
Peds. 1005:115:14281431
• Listen carefully and respectfully to parent’s concerns• Share honestly what is and is not known about risks and
benefits of the vaccine• Assist parents in understanding that risks of immunization
should be considered in comparison of risk of not being immunized
• Discuss concerns about specific vaccines• Discuss concerns about multiple shots• Explore whether cost is a reason• Respect (and document?) continued refusal• Generally avoid discharging patients because of refusal
Summary
• Vaccines have had a major impact on disease incidence (>95% reduction)
• Immunization coverage at record high• Extensive process for risk assessment and
risk management• Major shortcoming is in risk communication• Providers need to listen and communicate
effectively
Talk with people,not to them or at them