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 cohortZhou 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 waterMoher 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

• 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 championCharitha Gowda and Amanda F DempseyHuman Vaccines &

Immunotherapeutics 9:8, 1755–1762; August 2013F Dempsey2,

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

• 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 non-standard 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%

Pediatrics April 2015

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?

• 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

Vaccine 2013

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 2013AUTHORS: 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