Bruce Gellin, MD,MPH Executive Director National Network for Immunization Information

1. Immunization: Have We Become Victims of Our Success?ANA 2002 Biennial ConventionPhiladelphia, Pennsylvania Bruce Gellin, MD,MPH Executive Director National Network for Immunization Information Vanderbilt University School of Medicine Vanderbilt University School of Nursing Nashville, Tennessee

2. Ten Great Public Health Achievements-United States • 1900-1999 • Vaccination • Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods • Healthier mothers and babies • Family planning • Fluoridation of drinking water • Recognition of tobacco use as health hazard

3. Comparison of 20th Century Annual Morbidity and Current Morbidity, Vaccine-Preventable Diseases 20th Century Annual Morbidity 2000 (Provisional) Percent Decrease Diphtheria Measles Mumps Pertussis Polio (paralytic) Rubella Congenital Rubella Syndrome Tetanus H. influenzae, type b and unknown (<5 yrs) 175,885 503,282 152,209 147,271 16,316 47,745 823 1,314 20,000 4 81 323 6,755 0 152 7 26 167 99.9 99.9 99.8 95.4 100 99.7 99.1 98.0 99.1 Source: CDC

6. Vaccine Concerns: As Old As Vaccines Themselves “The Cow Pock – or – the Wonderful Effects of the New Inoculation!” J. Gillray, 1802

9. It’s no longer enough to say, “Trust us, we’re the experts.” Physicians and health educators must deal fully and respectfully with the vaccine safety concerns of parents and patients.

10. Medline Search: “Vaccine Safety”1980-2000 Number of articles

11. True: Vaccines are Not Without Risk • No vaccine is 100% safe • No vaccine is 100% effective • All vaccines have possible side effects, most mild, rarely severe • The risk of disease far outweighs the risk of vaccine

12. False: Avoiding Vaccines Would Be "Safer" • By choosing not to vaccinate one takes on the risk of disease • Both vaccinating and not vaccinating carry risks • Children unvaccinated against measles are 35 times more likely than immunized children to catch the disease Salmon DA. Health consequences of religious and philosophical exemptions from immunization laws. JAMA 1999

13. Arthritis Asthma ADD Autism Brain Damage Cancer Chronic Fatigue Syndrome Diabetes Gulf War Syndrome Infantile Spasms Inflammatory Bowel Disease Multiple Sclerosis Neuroimmune Dysfunction Sudden Infant Death Syndrome Temporal Associations Between Vaccinations and Serious Illnesses Cause Public Concern

14. Temporal vs. Causal Associations:Is Sequence Consequence? B Disease A Exposure (Vaccine, Drug, Diet, Occupation Others)? Time • Direct and only cause? • One of multiple potential causes? • Co-factor/indirect cause, trigger? • Coincidental? From: Pless, CDC

15. Risk Perception • Science is secondary to value judgments that people make concerning risks. • None of the leading factors of how people make decisions are technical or scientific. • Source credibility is key. • As a result, communication about risk must be developed through a process that essentially works backwards from the value judgments people make about risk information.

16. Features of a Postmodern Society • Distrust of science • Greater attention to risk • Better access to real-time information • Readiness to recur to the judiciary • J.A. Muir Gray • Lancet 1999; 354:1550-1553

17. Risk communication “The difficulty does not lie with our audience. Rather, we have failed to understand our audience. We repeat what they know and and neglect what they don’t. Our job is to figure out what has the greatest value to our audience and relay it clearly.” Baruch Fishoff Carnegie Mellon University

18. Presenting Risk Information: What’s Best?(unpublished 2001 data, CDC working paper) 1. “A serious reaction to this vaccine occurs about 1 to 3 times per 10,000 doses.” 2. “About 1 to 3 children out of 10,000 who receive this vaccine will experience a serious reaction.” 3. “This vaccine rarely causes serious reactions-- about 1 to 3 children out of 10,000 who receive it.” 4. “This vaccine is very safe-- 9,997 children out of 10,000 who receive it will experience no adverse reaction.”

19. Presenting Risk Information: The Findings(unpublished 2001 data, CDC working paper) 16% 27% 24% 33% 1. “A serious reaction to this vaccine occurs about 1 to 3 times per 10,000 doses.” 2. “About 1 to 3 children out of 10,000 who receive this vaccine will experience a serious reaction.” 3. “This vaccine rarely causes serious reactions-- about 1 to 3 children out of 10,000 who receive it.” 4. “This vaccine is very safe-- 9,997 children out of 10,000 who receive it will experience no adverse reaction.”

20. INCREASE CONCERN Unclear benefits Uncontrollable Involuntary Children at increased risk Delayed effects Risk to future generations Lack of trust in responsible institutions Much media attention Effects irreversible Caused by human actions or failures DECREASE CONCERN Clear benefits Controllable Voluntary Children risk not increased Immediate effects No risk to future generations Trust in responsible institutions Little media attention Effects reversible “Acts of nature/God” Factors important in risk perception

21. Do Parents Understand Immunization?A National Telephone Survey in the US • The majority of parents understand • the benefits of immunizations and • support existing policies and • programs. Gellin et al. Pediatrics 2000;106:1097-1102

22. Do Parents Understand Immunizations?A National Telephone Survey in the US -84% would not opt out of any vaccines -84% believe school immunization mandates protect their children -83% immunize to prevent disease -79% do not believe unimmunized children should be allowed in schools But… Gellin et al. Pediatrics 2000;106:1097-1102

23. Do Parents Understand Immunizations? Many parents have important misconceptions about vaccines and immunization practices and policies that could erode their confidence in immunizations. -25% believe immune systems are weakened by too many vaccines -23% think children get more vaccines than are good for them -19% of parents do not think vaccines are proven safe prior to use in the US Gellin et al. Pediatrics 2000;106:1097-1102

24. Recommended childhood immunization schedule: 1985

25. Recommended Childhood Immunization Schedule United States 2001 Vaccines are listed under routinely recommended ages. Bars indicate range of recommended ages for immunization. Any dose not given at the recommended age should be given as a "catch-up" immunization at any subsequent visit when indicated and feasible. Ovals indicate vaccines to be given if previously recommended doses were missed or given earlier than the recommended minimum age. 1 2 4 6 12 15 18 24 4-6 11-12 14-18 Age Birth yrs mos mos mos yrs mo mos mos mos mos yrs Vaccine Hepatitis B Hep B #1 Hep B #2 Hep B #3 Hep B Diphtheria, Tetanus, Pertussis DTaP DTaP DTaP DTaP DTaP Td H. Influenzaetype b Hib Hib Hib Hib InactivatedPolio IPV IPV IPV IPV Pneumococcal Conjugate PCV PCV PCV PCV Measles, Mumps, Rubella MMR MMR MMR Varicella Var Var Hepatitis A Hep A —in selected areas Approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP).

26. Immunogenic Proteins, Polysaccharides in Vaccines 1900 1960 1980 2000 Vaccine Proteins Vaccine Proteins Vaccine Proteins Vaccine Proteins smallpox ~200 smallpox ~200 diphtheria 1 tetanus 1 wc-pertussis ~3000 polio 15 diphtheria 1 tetanus 1 wc-pertussis ~3000 polio 15 measles 10 mumps 9 rubella 5 diphtheria 1 tetanus 1 ac-pertussis 2-5 polio 15 measles 10 mumps 9 rubella 5 Hib conj. 2 varicella 69 pneumo conj. 8 hepatitis B 1 TOTALS: 1 ~200 5 ~3217 7 ~3041 11 123-126 Modified from Offit PA, et al. Pediatrics January 2002

27. 1900 1960 1980 2000 ~ 200 ~ 3217 ~ 3041 ~ 123-126 Immunogenic Proteins, Polysaccharides in Vaccines Year # Vaccines # Antigens 1 5 7 11

28. “If concerned, where would you go first for information about your concern?” (unpublished 2001 data, CDC working paper) %1st Choice%2nd%3rd Physician 81% 10% 3% Friend w/ med or nurse training 3% 34% 22% Family member 10% 21% 22% Internet site 2% 12% 11% Magazine/newspaper 1% 8% 12% Friends 1% 4% 10% Religious/spiritual source 1% 2% 2%

29. Attitudes of Vaccinators in Canada (Quebec, 1998) In general, the vaccines that are recommended for use in infants and children are: GPs Peds Nurses • Safe 87% 88% 57% • Effective 77% 85% 52% • Necessary 92% 94% 68% Dionne, 2001

30. Health Care Professionals Policy Makers and Legislators Parents/Patients/Families Intermediaries Employers Media Advocacy Groups Insurers Key Voices in the Immunization Dialogue

31. “Then we’ve agreed that all of the evidence isn’t in, and that even if all of the evidence were in, it still wouldn’t be definitive”

32. Improving the Immunization Dialogue All health-care workers, from general practitioners to midwives, need to be kept up to date with developments in the debate and learn how to discuss, rather than dismiss, parents' fears. The Economist February 14, 2002

33. NN National Network for Immunization Information www.immunizationinfo.org Infectious Diseases Society of America Pediatric Infectious Diseases Society American Academy of Pediatrics American Nurses Association American Academy of Family Physicians National Association of Pediatric Nurse Practitioners American College of Obstetricians and Gynecologists

34. Immunization Resources • www.immunizationinfo.org • Resource Kit: Communication with Patients About Immunizations • Immunization Newsbriefs