Patricia Stinchfield, RN, MS, CPNP

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Centers for Disease Control and Prevention
Vaccine Safety Netconference June 12, 2008
Effectively Addressing Parents Concerns about
Immunizations
Patricia Stinchfield, RN, MS, CPNP Director,
Infectious Disease/Immunology/Infection
Control Advisory Committee on Immunization
Practices, voting member representing National
Association of Pediatric Nurse Practitioners
(NAPNAP)
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Experience and Values Drive Risk Communications

• My experience 30 years as a pediatric RN, 21 of
  those as a Pediatric Nurse Practitioner in
  Infectious Disease/Immunology
• Cared for numerous children with vaccine
  preventable diseases including pertussis,
  measles, influenza, severe varicella and
  rotavirus and pneumococcal, Hib and meningococcal
  meningitis
• Parents and many providers today have never seen
  these diseases so the benefit of vaccines is
  invisible
• When you care for the sickest of the sick, the
  bias is strong in favor of vaccination.

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Vaccine Debates Impact on Parents

• National vaccine debates cause great vaccine
  communication challenges at the patient care
  level
• Parents can be confused, misinformed or fearful
  of vaccines because of a story they read/see.
• The vaccine communication challenges are many
• The perspective is often skewed
• (1 mom interviewed on news who vaccinates
  represents 98 of parents, whereas the other mom
  choosing not to vaccinate interviewed represents
  2 of parents)

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Provider Impact

• 40 of providers surveyed did not mention vaccine
  risks with patients (Davis)
• Research supports that physicians say little to
  parents about immunizations (Ball et al)
• Parents want info from providers (Gellin)
• Nurses reported the most education in
  riskbenefit communication (Davis, et al) but may
  not always have the responsibility to educate
• With recent media attention to the topic, more
  and more providers are spending considerably more
  time discussing immunization concerns with parents

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An Infants Immune System is Too Weak for
Vaccines?

• Take a moment early on and briefly describe the
  power of the human immune system
• T and B lymphocytes are abundant in a lock and
  key ability to deal with antigens individually
  therefore no immune system overload
• The ocean analogy
• Even premature babies have the immune capacity to
  respond to inactivated vaccines
• With few exceptions, when they are 60 days old,
  even in an NICU, babies are started on their
  immunization series and can make protective level
  antibodies

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So Many So Soon,So Many at One Visit

• Vaccinate by the recommended schedule that has
  been thoroughly reviewed by experts, most of whom
  are also parents
• There is no physiologic reason to design an
  alternative immunization schedule
• There is no biological rationale for splitting up
  a dose
• To choose to delay is to choose to take a risk
• If avoidance of harm is the goal, to prolong
  prevention is to delay protection
• Choosing to not vaccinate not only potentially
  endangers this baby, but others as well.

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Is Thimerosal the Problem?

• The preservative thimerosal has been removed from
  vaccines with the exception of multi-dose
  influenza
• Multi-dose vials of influenza vaccine contain
  thimerosal as a preservative
• This requires time for conversation in the
  clinics about thimerosal, even in mass influenza
  vaccination settings
• Danish cases of autism rose substantially after
  thimerosal was removed in 1992 (AJPM 8/2003)
• Theoretical/unproven risk with thimerosal vs.
  real/considerable risk with disease
• Education on the lack of scientific support for
  thimerosal as a causative agent of autism is as
  necessary as ever

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Do Vaccines Cause Autism?

• The Institute of Medicine has reported that there
  is no correlation between thimerosal content in
  vaccines and autism (NEJM 9/07)
• We do not yet know the cause of autism and
  resources would be best spent understanding this
  better
• Epidemiological studies in different parts of the
  world have shown no relationship vaccines and
  autism (Danish study of 500,000 children over 7
  years found no association. NEJM 2002)
• Vaccine Safety Datalink did not show a
  relationship between vaccines and autism or other
  neurodevelopmental disorders (Pediatrics, 11/03)
• Temporal association between things is not the
  same as a causal association

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Communication Challenges

• Time
• Prevention
• Complicated science
• Disease versus vaccine
• Emotions (fear, anxiety) can be driving
  conversation

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Communication Challenges

• Languages
• Perceptions
• Mind made up mentalities
• Information resource challenges leads to
  misinformation

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What Strategies Can Reduce Myths and
Misperceptions?

• Listen. What is the root of the
  misunderstanding? Fear? Knowledge deficit?
  Attitude? Experience? Emotions? Beliefs?
• Balanced mediais it even possible?
• Modeling Vaccinate Health care Professionals
• Storytelling Sharing real experiences

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Wednesday, January 31, 2007

• Television news airs photos a family has shared
  of their 8 year old son Lucio who died of
  Influenza A.
• His parents hope is to alert parents in order to
  prevent other children from dying.
• Droves of parents called providers concerned
  asking for influenza vaccine
• Telling the real stories makes a difference

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Reasons Parents Give Not to Immunize

• Medical
• Contraindications
• Precautions
• Safety
• -Side effects

• Philosophical
• Individual rights
• Alternative health
• Religious
• Not health care consumer
• Human or animal tissue in vaccines
• Good health is achieved through seeking God

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What is Safe?

• SAFE No Harm from the vaccine?
• No vaccine is 100 safe
• SAFE No Harm from the disease?
• No vaccine is 100 effective
• Have we communicated realistic expectations?
• Communicate that the safety and effectiveness of
  receiving vaccines is far less risky than being
  un-immunized
• To do nothing is to take a risk

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Practical Thoughts on Reducing Challenges

• Establish Rapport-trust is vital
• Determine understanding-what have their
  experiences been?
• Break down emotional barriers
• Engage in 2 way conversation
• Give personal provider experience with vaccine
  safety issues

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Practical Thoughts continued

• Encourage questions
• Give perspective real life examples
• Provide supporting information
• Focus Keep control without being controlling

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Enhancing Vaccine Communication

• Recognize the challenges
• Meet them where they are
• Share the goal of informed decision-making in
  partnership
• Engage in a dialogue with trust and open
  understanding
• Be evidence based and as definitive as the
  science allows
• Individualize the message and methods of
  communication.

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Enhancing Vaccine Communication

• Use current information, VIS
• Communicate clearly in plain language with visual
  aids
• Use analogies
• Keep it interactive
• Use videos, group teaching
• Provide reliable websites
• Parent-to-parent sessions
• Taped phone messages

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Use the Five Cs of Effective Communication

• Chemistry
• Clarity
• Consistency
• Credibility
• Caring

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Simple is Better

• Keep it simple
• A one sentence description of the disease
• A word about its prevalence/dangers in your
  community and the world
• Describe the vaccine benefits
• Describe the vaccine risks and the risks of not
  immunizing
• Advise about normal, local responses
• Inform about what to do in the event of a severe
  adverse reaction
• Emphasize the return visits based on the
  recommended schedule

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Emphasize Ongoing Safety Monitoring

• Many ways that vaccines are monitored on an
  ongoing basis
• Vaccine Safety Datalink (large HMO data analysis)
• VAERS (Vaccine Adverse Event Reporting System
  through the CDC FDA, relies on providers)
• CISA centers (6 centers for immunization safety
  assessments)
• Ongoing post-marketing surveillance by
  manufacturers

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Summary

• Many vaccine communication challenges exist in
  the practice setting today
• Determine the origin of concerns
• Address concerns with effective riskbenefit
  communication strategies
• Underscore safety is top priority for us all
• Safety monitoring is ongoing
• Utilize creative strategies to communicate
  efficiently such as group classes, taped phone
  messages, reliable resources brochures,
  parent-to-parent sessions
• Keep communication clear, compassionate yet
  confident

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