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When the Answer to Vaccines Is

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When the Answer to Vaccines Is Gretchen LaSalle, MD MultiCare Rockwood Clinic, When the answer to vaccines Spokane, Wash [email protected] is “No” The author reported no potential conflict of interest relevant to this article. This comprehensive review provides point-by-point, data-supported responses to 13 common vaccine misconceptions and concerns your patients may have. e all know how challenging and time-consuming it PRACTICE can be to convince vaccine-hesitant patients that RECOMMENDATIONS vaccinations are what is best for them and their chil- ❯ Use a presumptive W dren. Patients are bombarded with misinformation through approach when dis- the news and social media that seeds or “confirms” their cussing vaccines with patients/parents. A doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims ❯ Offer vaccines at every that are a mere click or scroll away. opportunity; provider To better prepare for this challenge, this article details a recommendation is the most important factor in getting practical approach to discussing vaccines with your patients. patients to vaccinate. A Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine ❯ Focus on the cancer misconceptions and overcome the barriers that stand in the prevention aspect of the way of these lifesaving interventions. human papillomavirus vaccine to improve rates of vaccine acceptance. A A few important baseline concepts Strength of recommendation (SOR) In discussing vaccination with our patients, it is important to A Good-quality patient-oriented evidence keep the following in mind: B Inconsistent or limited-quality ❚ Patients don’t refuse vaccinations just to make our lives patient-oriented evidence difficult. They truly are trying to make the best decisions they C Consensus, usual practice, opinion, disease-oriented can for themselves and their families. Recognizing this can sig- evidence, case series nificantly reduce frustration levels. ❚ Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a sec- ond thought. In fact, studies show that provider recommen- dation is the most important factor in patients’ decisions to vaccinate.1 ❚ Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vac- cines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ 348 THE JOURNAL OF FAMILY PRACTICE | JUNE 2018 | VOL 67, NO 6 Studies show that provider recommendation is the most important factor in patients' decisions to vaccinate. minds. Studies show that a presumptive ap- ❚ If at first you don’t succeed, try again INSTANT proach (eg, “Today we are going to provide the because patients often have an experience tetanus, human papillomavirus [HPV], and that changes their mind. Perhaps a friend POLL meningitis vaccines”) is a much more effective died of throat cancer or a family member What percentage way to get patients to vaccinate.2 developed a complication of the flu that re- of your patients ❚ Barriers to counseling. Health care quired hospitalization. You never know when (including par- providers report a variety of barriers to ef- something will influence patients’ choices. ents of patients) ❚ fective vaccine counseling (limited time and Don’t wait for scheduled well visits. express reticence resources, lack of confidence in addressing Use every patient encounter as a means to or concerns about 3 patients’ concerns, etc). In addition, provid- catch patients up on missing vaccinations. vaccinations? ers sometimes worry that strong encourage- ment of vaccination will create an adversarial n 0%-10% relationship with vaccine-hesitant patients. Common misconceptions and n 11%-20% Developing a good rapport and trusting rela- concerns and how to counter them tionship, as well as using motivational inter- I’ve heard that vaccines can actually n 21%-30% viewing approaches, can help communicate make you sick. IMAGE: 1. n the importance of vaccines, while leaving When patients raise this concern, start with 31%-40% © JOE GORMAN patients with the sense that you have heard an explanation of how vaccines work. Ex- n > 40% them and respect their intentions. (See “Fa- plain that our bodies protect us from foreign cilitate vaccine discussions using these 2 ap- invaders (such as viruses and bacteria) by mdedge.com/jfponline proaches,” 4-7 page 350.) mounting an immune response when we are MDEDGE.COM/JFPONLINE VOL 67, NO 6 | JUNE 2018 | THE JOURNAL OF FAMILY PRACTICE 349 invaders by the time we are exposed to an ac- tive infection. Facilitate vaccine discussions ❚ To use an analogy to war, instead of 4-7 using these 2 approaches being subjected to a surprise attack where we C.A.S.E. suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to Corroborate defend ourselves so that our bodies are now Acknowledge concerns and find some point on which you can able to successfully fight off that attack. agree. Because the majority of vaccines are Example: “It sounds like we both want to keep your child healthy killed virus vaccines, they cannot cause the and safe.” illness against which they are meant to pro- About me tect. Triggering the immune system may Describe what you have done to build your expertise on the subject. make some recipients feel a little “under the Example: “I have been practicing medicine for 15 years and have weather” for a day or 2, but they do not make spent a great deal of time researching the data on vaccinations.” us “sick.” Science Live attenuated vaccines are similarly Review the data and science behind vaccines. safe for those with a healthy immune sys- Example: “Vaccines are more rigorously studied and safer than tem. We don’t administer them, however, to almost any other intervention we have in medicine.” people who have a weakened immune sys- Explain/advise tem (eg, pregnant women, newborns, people Explain your recommendations, based on the science. with acquired immunodeficiency virus, or Example: “This is why I vaccinate my children, and this is why I patients receiving chemotherapy or other recommend this vaccine for your child.” types of immunosuppression) because these patients could develop the illness that we are 3As trying to protect against. Ask Don’t stop at a patient’s first “No.” Respectfully dig a bit deeper. Don’t vaccines cause autism? Aren’t they toxic to the nervous system? Example: “What questions do you have about the vaccines we are 2. The largest setback to vaccination efforts in recommending today? Tell me what worries you about them.” recent history was a 1998 study by Andrew cknowledge A Wakefield that suggested that vaccination Acknowledge your patient’s concerns. (specifically the mercury [in the form of thi- Example: “You are obviously a very devoted parent, and I know merosal] present in the measles, mumps, that you are trying to make the best decision you can for your rubella [MMR] vaccine) was linked to the de- child. With everything we see on the news and social media, it’s 8 not always easy to know what to believe about vaccines.” velopment of autism. This research was sub- sequently debunked,9 and the author of the Advise 1998 study was stripped of his medical license Advise patients/parents of the facts about vaccines and provide a for falsifying data. However, the damage to strong recommendation to vaccinate. vaccination efforts had already been done. Example: “Depending on the year, influenza kills 12,000 to 56,000 ❚ Aluminum. Thimerosal is not the only people annually; the vast majority of those who die did not receive the flu vaccine.7 My family and I get the flu shot every agent that patients may find concerning. year, and I strongly encourage you and your children to get this Some also worry about the aluminum con- lifesaving vaccine.” tent of vaccines. Aluminum works as an ad- ditive to boost the body’s immune response to a vaccine. It is used only in killed virus vac- cines—not in live attenuated ones. The Agency exposed to these proteins. Vaccinations work for Toxic Substances and Disease Registry by exploiting this immune response; they monitors minimum risk levels (MRLs) of alu- expose the body to killed or weakened viral minum and other compounds in potentially or bacterial proteins in a safe and controlled hazardous substances. The amount of alu- manner. In this way, our immune system will minum in vaccines is far below the MRL for have already developed antibodies to these aluminum, which is 1 mg/kg/d.10 (See “The 350 THE JOURNAL OF FAMILY PRACTICE | JUNE 2018 | VOL 67, NO 6 VACCINES facts about thimerosal and aluminum in vac- In Britain, a drop in the rate of pertus- cines,”11-16 on page 359.) sis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 I’m healthy. I never get sick. Why do I cases and 36 deaths by 1978. There was no de- 3. need vaccinations? crease in hygiene or sanitation standards to A good way to counter this comment is to re- explain this rise.21 spond: “Saying you don’t need vaccinations because you never get sick is like saying you Vaccines are just another way for don’t need to wear a seat belt because you’ve 5. “big pharma” to make “big money.” never been in a car accident.” Advise patients Patients may benefit from knowing that in that we seek to vaccinate all members of a the earlier days of vaccines, pharmaceutical community—not just those who are sick or at companies actually moved away from pro- high risk—to protect ourselves and to provide duction of vaccines because they were not “herd immunity.” It’s important to explain very profitable.
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