Communicating with parents, providers, and the media

1. Communicating with parents, providers, and the media Alan R. Hinman, MD, MPH October 16-17, 2007

2. 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?

3. 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

4. Balancing benefits and risks • Use of vaccine depends on balance of benefits and risks • This balance may change over time • For example, OPV/IPV

5. 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

6. Risk Communication • Risk has technical and cultural components • Technical – hazard • Cultural – “outrage” Risk = Hazard + Outrage Source: Sandman 2002

7. Outrage FactorsLow High Voluntary Coerced Natural Industrial Familiar Exotic Not memorable Memorable Not dreaded Dreaded Chronic Catastrophic Knowable Unknowable Individual control Controlled by others Fair Unfair Morally irrelevant Morally relevant Trustworthy sources Untrustworthy sources Responsive process Unresponsive process

8. 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

9. 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

10. Evolution of Immunization Program and Prominence of Vaccine Safety

11. 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%

12. 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

13. Reasons for lack of supportfor immunizations • Ignorance • Fear • Contraindication • Religion • Philosophy • “Informed” opposition

14. 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

15. Parental concerns and behavior after immunizationGust. 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

16. 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…

17. 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

19. 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 Vaccine requirements2006-2007 school year

20. Exemptions to immunization requirements2006-2007 school year Medical 50 states Religious 48 states Philosophical 17 states

21. Frequency of exemptions2003-2004 school year Type#repHighState#>1.0% Med 2.6% IN 4 Rel 3.2% WY 4 Phil 3.6% WA 10

22. Children entering kindergarten with vaccination personal belief exemptions, 2006 Percent PBEs Number PBEs 0.00 – 0.99 1.00 – 2.99 3.00 – 4.99 5.00 – 14.37 0 – 49 50 – 99 100 – 199 200 - 1102 California Dept of Health Services Immunization Branch

23. 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

24. 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

25. 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

28. 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

43. Antivaccination Web Sites - 1 • Identified 22 antivaccination web sites • Studied content and design attributes Source: Wolfe et al JAMA 2002;287:3245-3248

44. 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

45. 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

46. Antivaccination activists on the world wide webDavies. 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”

47. Antivaccination activists on the world wide webDavies. 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

48. Subtexts in anti-immunization articlesLeask. 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

49. 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

50. 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