Vaccine Hesitancy: Definition and Dimensions

Noni MacDonald MD, FRCPC Dalhousie University, Canadian Centre for Vaccinology Halifax , Canada IAIM Joint Regional Meeting Feb 2, 2017

1 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

2 Vaccine Hesitancy Hesitancy: as old as vaccination itself Since Jenner first scraped cow-pox blisters & innoculated people, see examples resistance to vaccination

Vaccine refusal: associated with outbreaks many www.freewebs.com/edward_jenner/the_cow_pock_ diseases in many different large_cartoon.jpg countries, including: • Pertussis in the UK, US and Japan • Measles in USA, Canada, France Hesitancy can affect any etc vaccination program • Polio in Nigeria • Tetanus in Philippines and Kenya 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. 3 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 4 MacDonald NE and SAGE Working Group on Vaccine Safety. Vaccine 2015; 33(34):4161-4 Hesitancy – a Global Problem: 2014 JRF Most common reasons cited* 1) risk/benefit of vaccines (epidemiological and 146 (79%) scientific evidence) 185 (95% ) 194 completed responded hesitancy 2) knowledge/awareness countries to JRF indicators issues around vaccines

3) Religion/culture/gend er/socio-economic issues

* Only 29% based on surveys. • Marti et al article revision submitted5 Vaccine Hesitancy Perceived risks VPD low; vaccination not deemed a Determinant Categories necessary preventive action. Other life /health responsibilities higher Trust in vaccines, in priority at time delivery system, in the policy-makers Complacency who decide which Physical access- vaccines are needed availability, and when. affordability, willingness to pay; geographical access, Convenience ability to understand Confidence (language, health literacy); appeal of Antivaxers May influence immunization services

SAGE Working Group on Vaccine Hesitancy Final Report www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_6 hesitancy.pdf?ua=1 Risk Perception and Vaccine Decisions 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 Kahan D. Sci 2103; 342: 53-4 Smith JC, Appleton M, MacDonald NE. information Adv Exp Med Biol 2013; 764: 81-98. 7 Vaccine Hesitancy influenced 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):518-9 8 Addressing Dimensions of Vaccine 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 Complex - strategies that improved vaccine uptake not simple - multicomponent more effective than single problem

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): 4191-203.9 12 Approaches to Enhance Vaccine Acceptance/Address Hesitancy At Immunization Program At individual Level Level 7. HCP – key role in imm 1. Detect and address hesitancy 8. Don’t dismiss from practice 2. Ensure HCW best 9. Use effective parental immunization practices discussion techniques 3. Utilize evidence based 10. Use clear language strategies known to ↑ uptake 11. Reinforce role community 4. Effective Communication immunity plan 12. Address pain at 5. Educating children, youth, immunization adults on the importance immunization for health 6. Work collaboratively Dube E, MacDonald NE. Lancet ID 2016; 10 1. Everyone is not Same: Detect and Address Vaccine Hesitant Subgroups Reasons for hesitancy vary; Geographical distribution of n - not uniform over pop ; measles cases in Belgium Jan – - may change over time March 2011 n=151 - 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 outbreak started in anthroposophical schools Program- “TIP” in Ghent (Flanders) in February. Butler R, MacDonald N. Sabbe M et. Euro Surveill 2011; 16(16):pii=19848. 11 Vaccine 2015;33:4176-9 . 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 HCP immunization education key Ensure HCW immunization up to date

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 12 Shibli et al Vaccine online Dec 30, 2016 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 13 Journal of Adolescent Health 2016; 59:S40eS48 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 Grabenstein JD. Vaccine 2013;31:2011-23 - exception Christian Scientists WHO EURO Collaborative Project with Sweden: “Hard-To-Serve” pop https://www.fhi.no/globalassets/migrering/ dokumenter/pdf/tailoring-immunization- - did not look at anthroposophical - programmes-an-example-from-sweden-.pdf Bystrom et al Vaccine 2014;32: 6752-7 Polio scare Israel 2014: multi pronged approach- including work with IMA, IPA, rabbis, imams etc Kaliner E et al. Euro Surveill. 2014;19(7):pii=20703

14 Ease of Access Matters HPV 3 dose Coverage among Flu Vaccine: Pharmacies, Schools Girls in high income countries

• 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 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- 15 2015report Reminders Make a Difference Systematic review: effect on 0-5 years imm; adolescents - postal and telephone reminders help Work in HIC, MIC, LIC Harvey H, Reissland N, & Mason J. Vaccine2015; 33(25): 2862-2880. SMS infant vax reminder LMIC(Guatamala City ) Domek et al Vaccine 2016; 34: 2437-2443 Das JK et al Journal of Adolescent Health 2016; 59:S40eS48 Text Messages in general practice for flu vax Herret E et al BMJ Open 2016;6:e010069. 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 16 Mandatory Vaccination and $ Incentives Mandatory Immunization for school entry Outcome: complex area US- ↑rates non medical exemptions; not always lead to high uptake -may backfirewww.dcclothesline.com 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 0154603 Moss et al Pediatrics 2016;138(6): e20161414 ; Wigham et al Peds 2014; 134:e1117–e1128 17 Lee, C., Robinson JL. J Infect 2016 72.6: 659-66. 4. Effective Communication • Knowledge = Action Know Do • 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 Know • 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 18 Impact of Vaccine Messages: Varies Pro-vaccine messages: work for those +ve about vaccines: important for ↑ resiliency if –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 19 Haase et al J Health Comm 2015:20:920-9 Nyhan & Reifler Vaccine 2015;33: 459-64 Amount and Type of Information Matters

CDC HPV vax information; compared impact of a) stand info alone b) 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 Work Freemantle, 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. Van der Linden, S et al Climatic Change 2014 126; 255-262. Van der Linden, S et Global Chalenges 2017, 1600008 What about vaccine misinformation ? No similar studies WHO EURO: How to respond to vocal vaccine deniers in public Schmid P, MacDonald NE, Habersaat K, Butler R. Vaccine 2016 Oct 13. pii: S0264-410X(16)30914-8 22 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 vac edu 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 Shared objectives: program (i) communicate proactively Public health on immunization, Academia (ii) prepare for issues that may HCPs arise HCP societies (iii) Understand challenges better through existing and Manufacturers * future research Civil Society Organizations Global agencies saves time, resources, Private Sector adds voice, NGOs enhances credibility health worker vaccine message

24 Thompson A , Watson M. Vaccine 2016; 34 :1989–92 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 Fuchs EL. Self-reported prenatal influenza vaccination and early 25 childhood vaccine series completion Prev Med 2016;88: 8-12 8.Vaccine Refusers and Hesitant Refusers: Hesitant: • Do Not dismiss • Determine basis of hesitancy • Build trust – caring and – do not assume competence • Do not over estimate parental concerns • Not debate • Listen and listen • Maybe able to determine • Tailor response to concerns concerns with “ what would it take to move http://www.euro.who.int/en/health-topics/disease- you to a yes to accept prevention/vaccines-and- vaccines? immunization/publications/2012/if-you-choose-not- to-vaccinate-your-child,-understand-the-risks-and- • Responsibilities for responsibilities refusers WHO EURO HealyCM, Montesinos DP, Middleman AB. Vaccine 2014: 23;32(5):579-84 • Consider referral to Halperin B, Melnychuk R, Downie J, Macdonald N. “expert” Paediatr Child Health 2007;12(10):843-5. 26 9. Use Effective Parental Discussion Techniques a)Presumptive: Tell don’t ask:

74% accept n=51 4% accept n=1 13% provide own plan n=3

26% resisting n=18 83% resisting n=20

Opel et al Pediatrics 2013; 132: 1037-46

27 9. Use Effective Parental Discussion Techniques b) Address Concerns : • What do you think Open ended about vaccines? Motivational Interviewing questions •client centred, semi-directive, aimed at changing behaviour • I understand •shift from Affirmation •TALKING TO → WORKING WITH • You are concerned Listen by reflectively “ What would it take to move you to a yes to accept • Let me summarize vaccines?” Summarize

Tailor discussion to fit Healey CM and Pickering L. Pediatrics 2011;127: S127–S133 Leask et al. BMC Pediatrics 2012, 12:154 concerns 28 10. Use Effective Clear Language 1. Standard vocabulary

1000 Children 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 Tetanus 10% die risk or % even with ICU care = 100 in 6. Frame your message * 1000 7. Avoid using jargon ** MacDonald 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/ 29 Peters, E.,Bjalkebring. 2015. J Pers Soc Psychol 108.5: 802-22 Frame Vaccine Message Anxious about negatives: Pneumococcal conjugate vaccine > 99.9% safe better /more effective than 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; 30 Gesser-Edelsburg A et al.Disaster Med Public Health Prep. 2015 Apr;9(2):199-206. Focus on Gist Communication ( Fuzzy Trace Theory)

Verbatim Explicit Link GIST Establishes credibility Connects verbatim Helps comprehension and expertise with GIST and recall

Evidence based fact Scripted phase Bottom line meaning or Statistic

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/Immunity Not use Jargon: Herd Immunity • 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”

https://www.ted.com/talks/romina_libster_the_power_of_herd_immunity Broniatowski DA, Hilyard KM, Dredze M.Vaccine. 2016;34(28):3225-8 http://www.doh.wa.gov/Newsroom/2015NewsReleases/15119WAMeasles 32 RelatedDeath 12. Address Pain Mitigation 2015 Canadian Pain Guidelines ( GRADE): HELPinKids&Adults Taddio et al CMAJ 2015; 187:975-982. www.youtube.com/ - Covers age range: neonates to adults watch?v=KgBwVSYqf ps - 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 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 33 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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