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Vaccine Hesitancy:

Definition and Dimensions

Noni MacDonald MD, FRCPCDalhousie University,

Canadian Centre for VaccinologyHalifax , Canada

IAIM Joint Regional MeetingFeb 2, 2017

Conflicts of Interest

No relationship with commercial interests

i.e. no conflicts of interest

• Noni MacDonald:

professsor, Dalhousie University, Halifax Canada,

consultant and adviser to WHO EURO and WHO HQ

• Biases

I believe vaccines are safe, effective,

serious diseases can occur if not immunized

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Vaccine HesitancyHesitancy: as old as vaccination itselfSince Jenner first scraped cow-pox blisters & innoculated people, see examples resistance to vaccination

Vaccine refusal:

associated with outbreaks many diseases in many different countries, including:

• Pertussis in the UK, US and Japan

• Measles in USA, Canada, France etc

• Polio in Nigeria

• Tetanus in Philippines and Kenya

Hesitancy can affect any vaccination program

Wolfe RM, Sharp LK. Anti-vaccinationists past and present. BMJ. 2002;325(7361):430-2.Dubé E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement:

influence, impact and implications. Expert Rev Vaccines. 2015;14(1):99-117.

www.freewebs.com/edward_jenner/the_cow_pock_

large_cartoon.jpg

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Definition of Vaccine Hesitancy

Vaccine Hesitancy

• refers to delay in acceptance or refusal of vaccines despite availability of vaccine services

• complex and context

specific varying across time,

place and vaccines

Problem in HIC, MIC ,LIC

SAGE Working Group on Vaccine Hesitancy Final Report

www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_h

esitancy.pdf?ua=1

MacDonald NE and SAGE Working Group on Vaccine Safety. Vaccine 2015; 33(34):4161-44

Hesitancy – a Global Problem: 2014 JRF

194 countries

185 (95% ) responded

to JRF

146 (79%) completed hesitancy indicators

Most common reasons cited* 1) risk/benefit of

vaccines (epidemiological and scientific evidence)

2) knowledge/awareness issues around vaccines

3) Religion/culture/gender/socio-economic issues

* Only 29% based on surveys. • Marti et al article revision submitted 5

Vaccine HesitancyDeterminant Categories

Perceived risks VPD low;

vaccination not deemed a

necessary preventive

action. Other life /health

responsibilities higher

priority at timeTrust in vaccines, in

delivery system, in

the policy-makers

who decide which

vaccines are needed

and when.

Physical access-

availability,

affordability,

willingness to pay;

geographical access,

ability to understand

(language, health

literacy); appeal of

immunization

services

Confidence Convenience

Complacency

SAGE Working Group on Vaccine Hesitancy Final Report www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf?ua=1

Antivaxers

May influence

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Risk perceptions are intuitive,

automatic and often unconscious

Emotions play a role in how people

make decisions

Emotions play a role in how people interpret numerical

information

Risk Perception and Vaccine Decisions

Kahan D. Sci 2103; 342: 53-4Smith JC, Appleton M, MacDonald NE.Adv Exp Med Biol 2013; 764: 81-98. 7

Vaccine Hesitancyinfluenced by many social, cultural, demographic and socio-psychological factors

• We are strongly influenced by what we think others around us are doing or expecting us to do

• We see causation in coincidences

• We see what we believe, rather than believing what we see

• We prefer anecdote and stories to data and evidence

• We are becoming increasingly hypervigilant to risk for our children

Dube E, MacDonald NE. Lancet ID 2016; 16(5):518-98

Addressing Dimensions ofVaccine Hesitancy

Systematic review of strategies peer-reviewed and gray literature (2007-2013) & Review of Reviews

Identified:

- no strategies to specifically overcome hesitancy in

all populations

- strategies that improved vaccine uptake

- multicomponent more effective than single

Jarrett C, Wilson R, O’Leary M, Eckersberger E, Larson HJ and the SAGE Working Group on Vaccine

Hesitancy Strategies for addressing vaccine hesitancy -a systematic review. Vaccine 2015;33(34): 4180-

90.

Dubé E, Gagnon D, MacDonald NE and the SAGE Working Group on Vaccine Hesitancy. Strategies

intended to address vaccine hesitancy: Review of published reviews. Vaccine 2015;33(34): 4191-203.

Complex not simple problem

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12 Approaches to Enhance Vaccine Acceptance/Address Hesitancy

At Immunization Program Level

1. Detect and address hesitancy

2. Ensure HCW best immunization practices

3. Utilize evidence based strategies known to ↑ uptake

4. Effective Communication plan

5. Educating children, youth, adults on the importance immunization for health

6. Work collaboratively

At individual Level 7. HCP – key role in imm8. Don’t dismiss from practice

9. Use effective parental discussion techniques

10. Use clear language

11. Reinforce role community immunity

12. Address pain at immunization

Dube E, MacDonald NE. Lancet ID 2016;

1. Everyone is not Same: Detect and Address Vaccine Hesitant Subgroups

Reasons for hesitancy vary;

- not uniform over popn;

- may change over time

- vary by vaccine

- may be clustered

At program level: key to identify subgroups low immunization- hard if no immunization registry

WHO EUR: The Guide to Tailoring Immunization Program- “TIP”

Butler R, MacDonald N. Vaccine 2015;33:4176-9

outbreak started in anthroposophical schools in Ghent (Flanders) in February.

Geographical distribution of measles cases in Belgium Jan –

March 2011 n=151

Sabbe M et. Euro Surveill 2011; 16(16):pii=19848..

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2. HCW Impact Vaccine Acceptance: Ensure HCW use Best Immunization Practices

HCW’s own immunization status: -reflects onto their patients’ status

HCW vaccine beliefs: - influences whether families will come forward and accept immunization

For optimal outcome patients need to hear from all HCW :

- consistent, accurate information: vaccine preventable disease risks, vaccine safety & benefits

- given in a respectful, positive manner

Zhang J et al Vaccine 2010, 28:7207-14; Collange F et al Hum Vac &Imm 2016; 12:1282-92 Favin M, et al International Health 2012; 4:229-238. Corace K et al Vaccine 2016; 34: 3235–3242

Shibli et al Vaccine online Dec 30, 2016

HCP immunization education key Ensure HCW immunization up to date

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3. Multiple dimensions to hesitancy: Use Effective Strategies to ↑ Vaccine Uptake a) directly target

• unvaccinated or under-vaccinated populations

• specific populations: e.g. local community, HCW;

b) aim to increase knowledge, awareness about vaccination*;

c) engage community leaders, religious or other influential leaders to promote vaccination in the community.

d) improve convenience and access to vaccination;

e) employ reminder and follow-up;

f) mandate vaccinations / sanctions for non-vaccination,

$$ incentives;

Jarrett C, et al.Vaccine 2015; 33:4180-90; Dube E et; Vaccine. 2015 14;33:4191-203; Das et al Journal of Adolescent Health 2016; 59:S40eS48

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Religion and Vaccines Review of major religions of world –

-most religious doctrines support

caring for others,

preserving life

having a duty to the community (family, neighbours, each other) i.e support vaccination

- exception Christian Scientists

- did not look at anthroposophical -

Polio scare Israel 2014: multi pronged approach- including work with IMA, IPA, rabbis, imams etc

Grabenstein JD. Vaccine 2013;31:2011-23

Kaliner E et al. Euro Surveill.

2014;19(7):pii=20703

WHO EURO Collaborative Project with Sweden: “Hard-To-Serve” pophttps://www.fhi.no/globalassets/migrering/dokumenter/pdf/tailoring-immunization-programmes-an-example-from-sweden-.pdfBystrom et al Vaccine 2014;32: 6752-7

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Ease of Access Matters HPV 3 dose Coverage among Girls in high income countries

Flu Vaccine: Pharmacies, Schools

http://www.statcan.gc.ca/pub/82-624-x/2015001/article/14218-eng.htm

Thompson A , Watson M Vaccine 2016 ; 34:1989-92; McConeghyy K, Wing C. Vaccine 2016 ;34:3463-8

http://deainfo.nci.nih.gov/advisory/pcp/annualReports/HPV/Part4.htm#sthash.GEesnLWt.IWYKoqM2.dpbs

Szilagyi P, et al Pediatrics 2016; 138: e2 0161746

https://www.gov.uk/government/publications/childhood-influenza-vaccination-pilot-programme-england-2014-to-

2015report

• UK 2014/15 Flu vax uptake in schools in UK > than pharmacy/GPs

• US: Flu vac uptake in schools> MD office- Rochester 54.1% vs 47.4%, P < .001

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Reminders Make a Difference Systematic review: effect on 0-5 years imm; adolescents

- postal and telephone reminders help

Work in HIC, MIC, LIC

Text Messages in general practice for flu vax

Seniors

2 min video on pneumococal vaccines email link sent to seniors prior to clinic visit - uptake -

6 mo study: 116- 75% opened message, 64% viewed all

if viewed 3 X uptake

Cameron KA et al 2016 J Gen Int Med 2016; 31 Suppl 2 S174

*

Harvey H, Reissland N, & Mason J. Vaccine2015; 33(25): 2862-2880.SMS infant vax reminder LMIC(Guatamala City ) Domek et al Vaccine 2016; 34: 2437-2443Das JK et al Journal of Adolescent Health 2016; 59:S40eS48

Herret E et al BMJ Open 2016;6:e010069.

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Mandatory Vaccination and $ Incentives Mandatory Immunization for school entry

Outcome: complex area

US- ↑rates non medical exemptions;

not always lead to high uptake -may backfire

UK- 150 years ago compulsory small pox vaccine: backlash

Canada Ont/ NB – not > imm uptake rates than other provinces no mandatory

Incentives:

HCW: UK -GP imm incentives ↑ uptake; US RCT Peds-no ↑

Patient incentives: sys review – not enough evidence but where done like: Australia

Dubov A, Phung C. Vaccine 2015;33: 2530-35; Salmon DA, et al. Lancet Infect Dis. 2015;15:872-3.

Dube E, MacDonald NE. CMAJ 2016 ;188:E17-8; Hull et al British Journal of General Practice.

2000;50:183-187; Fu LY et al. Pediatrics 2016; 137: e2 0154603Moss et al Pediatrics 2016;138(6): e20161414 ; Wigham et al Peds 2014; 134:e1117–e1128Lee, C., Robinson JL. J Infect 2016 72.6: 659-66.

www.dcclothesline.com

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4. Effective Communication• Knowledge = Action• Knowledge is important but not = change behaviour• Be proactive NOT just reactive • Communication is a two-way process: listening is key • Choose knowledge to focus on carefully• Target audience- tailor plan to fit • Many communication tools available* Evaluate impact and adjust as need to mantra needs to be: communicate, communicate, and

then communicate some more…..but be sure fit audience targeting

Goldstein S et al Vaccine 2015;33: 4212-4

Shelby A, Ernst K. Hum Vac and Immuno 2013; 9:1795-1801

*Odone et al Hum Vaccin Immunother 2015;11(1):72-82 (review effectiveness new media )

Thompson A , Watson M Vaccine 2016; 34:1989–1992

Know

DoKnow

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Impact of Vaccine Messages: VariesPro-vaccine messages: work for those +ve about vaccines: important for ↑ resiliencyif –ve about vaccines - not reduce vaccine misperceptions, nor

increase uptake-i.e. “backfire effect” reinforce negative views

Partisans see unfavorably slanted content as even more polarized than it is

Key: test messages in advance; tailor to fit

Nyhan B et al Pediatrics 2014;133; e835-42; Gunther AC et al Comm Res 2012;39: 439-57

Haase et al J Health Comm 2015:20:920-9 Nyhan & Reifler Vaccine 2015;33: 459-64 19

Amount and Type of Information Matters

CDC HPV vax information; compared impact ofa) stand info aloneb) a + VAERS summary c) a +VAERS full detailed reports serious AEFI ( no CA)

Schearer et al Vaccine 2016 ; 34: 2424-9 20

Targeted Messages Can WorkFreemantle, Western Aust

- low rates imm, esp amongst alternative lifestyle group

“ I Immunize” campaign

-multi pronged

- explicitly appealed to/ derived from: local values around social justice, parenting and alternative lifestyles

- did polarize views:

- BUT amongst alternative lifestyle group : now 77% +ve

Attwell K, Freeman M. Vaccine 2015; 33: 6235–6240.21

Inoculating Against Misinformation: Extrapolating from Climate Change

Research on climate change beliefs

Belief in a scientific fact increases as scientific consensus is highlighted

“Gateway Belief Model ”

What if false information presented? e.g. false meme- goes viral

Can confer attitudinal resistance: pre-emptively highlight false claims, refute potn counterarguments.

What about vaccine misinformation ? No similar studies WHO EURO: How to respond to vocal vaccine deniers in public

Van der Linden, S et al Climatic Change 2014 126; 255-262.

Van der Linden, S et Global Chalenges 2017, 1600008

22Schmid P, MacDonald NE, Habersaat K, Butler R. Vaccine 2016 Oct 13. pii: S0264-410X(16)30914-8

5. Shape Children’s Beliefs on

Vaccine Necessity, Benefits, Safety

Start early:

• Primary: what vaccines are, why needed, benefits, safety

• Secondary: weave into history, science and health

• Engage expert teachers and students - many resources

• Denmark- CPN – developing curriculum

• Canada -Ontario has included child and youth vacedu in 2020 Imm plan

Teachers Kit, National Immunization Poster Contest in Canada .

http://www.immunize.cpha.ca/en/events/imm-poster-contest.aspx

Opel D, Marcuse E. Human Vaccines & Immunotherapeutics 2013;9:2672–2673

http://www.health.gov.on.ca/en/common/ministry/publications/reports/immunization_2020/immunizati

on_2020_report.pdf

Nowak G, Gellin B, MacDonald NE, Butler R et al Vaccine 2015; 33: 4204–4211 23

6. Work Collaboratively Partnership: Key Asset

National immunization program

Public health

Academia

HCPs

HCP societies

Manufacturers *

Civil Society Organizations

Global agencies

Private Sector

NGOs

Shared objectives:

(i) communicate proactively on immunization,

(ii) prepare for issues that may arise

(iii) Understand challenges better through existing and future research

Thompson A , Watson M. Vaccine 2016; 34 :1989–92

saves time, resources, adds voice,

enhances credibility health worker vaccine message

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7.Key Role HCP in Vaccine Acceptance; “For all vaccines, the attitude of the physician ……is very

influential in the decision to vaccinate a child…..”Favin et al . International Health 2012; 4:229-238

Suryadevara M et al Vaccine 2015; 33: 6629–6634.

Parents received vaccine information from MDs: < vac concerns vs from friends/family/books

Wheeler M, Buttenheim A. Human Vaccines & Immunotherapeutics2013; 9:1782–1789

Witteman HO. Addressing vaccine hesitancy with values Pediatrics 2015;136 :215-7

HCP information or assurances - main reason why parents who planned to delay or refuse a vaccine for their child changed their minds

Gust, D.A., et al., Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics, 2008. 122(4): p. 718-25

Mother’s lack of uptake of flu vaccination in pregnancy

predicts infant immunization

25Fuchs EL. Self-reported prenatal influenza vaccination and early childhood vaccine series completion Prev Med 2016;88: 8-12

8.Vaccine Refusers and Hesitant Refusers: • Do Not dismiss • Build trust – caring and

competence • Not debate• Maybe able to determine

concerns with “ what would it take to move you to a yes to accept vaccines?

• Responsibilities for refusers WHO EURO

• Consider referral to “expert”

Hesitant:• Determine basis of hesitancy

– do not assume• Do not over estimate

parental concerns• Listen and listen • Tailor response to concerns

http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/2012/if-you-choose-not-to-vaccinate-your-child,-understand-the-risks-and-responsibilitiesHealyCM, Montesinos DP, Middleman AB. Vaccine

2014: 23;32(5):579-84Halperin B, Melnychuk R, Downie J, Macdonald N.

Paediatr Child Health 2007;12(10):843-5.

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9. Use Effective Parental Discussion Techniquesa)Presumptive: Tell don’t ask:

Opel et al Pediatrics 2013; 132: 1037-46

74% accept n=51 4% accept n=113% provide own plan n=3

83% resisting n=2026% resisting n=18

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9. Use Effective Parental Discussion Techniques

•client centred, semi-directive, aimed at changing behaviour•shift from •TALKING TO → WORKING WITH

“ What would it take to move you to a yes to accept vaccines?”

Tailor discussion to fit concerns

Healey CM and Pickering L. Pediatrics 2011;127: S127–S133

Leask et al. BMC Pediatrics 2012, 12:154

Open ended questions

• What do you think about vaccines?

Affirmation • I understand

Listen reflectively

• You are concerned by

Summarize • Let me summarize

b) Address Concerns : Motivational Interviewing

10. Use Effective Clear Language1. Standard vocabulary

2. Consistent denominator

3. Present risks/benefits

fairly: tell truth

4. Explain single event

probability (rain,not

rain) visual aides

5. Absolute numbers not relative risk or %

6. Frame your message *

7. Avoid using jargon **

1000 Children

Tetanus 10% die even with ICU care = 100 in 1000MacDonald NE et al. Help with Vaccine Hesitant Parents; an Update. Paediatrics & Child Health in press

Data graphics HPV & vaccine: www.informationisbeautiful.net/2011/is-the-hpv-vaccine-safe-v-2-0/

Peters, E.,Bjalkebring. 2015. J Pers Soc Psychol 108.5: 802-22 29

Frame Vaccine Message Anxious about negatives:

Pneumococcal conjugate vaccine > 99.9% safe

better /more effectivethan say <<0.1 % serious side effects

Often HCP focus discussions on side effects not

emphasize safety!At popn pandemic H1N1: Sweden +ve frame: 60%

Australia-ve frame : 18%Gerend MA, Shepherd MA, Shepherd JE Health Psychol. 2011;32:361-9.

Sandell T et al Scandinavian Journal of Public Health, 2013; 41: 860–865

NACI Canada. Canadian Immunization Guide

Tversky A, Kahneman D.Sci1981;211:453-8; Levin IP, Schneider SL, Gaeth GJ. Organ Behav Hum Decis

Process 1998;76:149–188; Reyna VF. Vaccine. 2012; 30(25): 3790–3797

Gesser-Edelsburg A et al. J Health Commun. 2015;20:1287-93;

Gesser-Edelsburg A et al.Disaster Med Public Health Prep. 2015 Apr;9(2):199-206.30

Focus on Gist Communication ( Fuzzy Trace Theory)

Evidence based fact or Statistic

Scripted phase Bottom line meaning

Verbatim Explicit Link GIST

Establishes credibility and expertise

Connects verbatim with GIST

Helps comprehension and recall

eg And the reason that’s important is…What that means to you is… So the thing to remember is… Bottom line -what I tell patients is……

Broniatowski D et al. Vaccine 2016; 34: 3225–3228 31

11. Present Concept:Community Protection/ImmunityNot use Jargon: Herd Immunity

https://www.ted.com/talks/romina_libster_the_power_of_herd_immunityBroniatowski DA, Hilyard KM, Dredze M.Vaccine. 2016;34(28):3225-8

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• Reinforcing added value community immunity helpful

US in 2015 – first measles death in 12 years in

immunocompromised patient

• BUT: not at expense note personal benefit

not all VPD preventable with this e.g. tetanus

• Jargon: can be a problem

“ herd Immunity”

http://www.doh.wa.gov/Newsroom/2015NewsReleases/15119WAMeaslesRelatedDeath

12. Address Pain Mitigation 2015 Canadian Pain Guidelines ( GRADE):

HELPinKids&Adults

- Covers age range: neonates to adults

- Updated & new evidence, twice as many interventions assessed vs 2010

- Rotavirus vaccine-many have high sucrose content –study show benefit give just before injection vaccines

- Breast feeding during the injection

- Give most painful vax last ** need help - manufacturers

Taddio et al CMAJ 2015; 187:975-982.

WHO : Report to SAGE on Reducing pain and distress at the time of vaccination. ( reviewed using AGREE)http://www.who.int/immunization/sage/meetings/2015/april/1_SAGE_latest_pain_guidelines_

March_24_Final.pdf

www.youtube.com/watch?v=KgBwVSYqfps

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Do Not to Neglect the Vaccine Accepting Group as Address Hesitancy

• Value their decisions

• Grow their resiliency against anti-vaccine

messages & sentiments

• Potentially powerful allies for immunization if speak up

– Imp for self and community

– Set social norm for nudge

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