Why hesitate? (A public health perspective) Christine Hahn, MD Idaho Division of Public Health

The evidence for a public health benefit of immunization is clear Greatly reduced rates of diseases Small risk to the individual receiving vaccination Overall improved population health 1/4/2016

Strategic Advisory Group of Experts (SAGE) on Immunization of the WHO definition of vaccine hesitancy “Delay in acceptance or refusal of vaccines despite availability of vaccinations services… It is influenced by factors such as complacency, convenience, and confidence.” 1/4/2016

Why isn’t everybody fully vaccinated? “Complacency” →Things seem OK; is a vaccine for this really needed? “Convenience” →Effort it takes to get vaccination done “Confidence” →Uncertainty whether a vaccine may actually be more harmful than beneficial; lack of confidence in the recommendation or generally in those giving the recommendation 1/4/2016

Complacency 1/4/2016

Diseases less common Cases, U.S. 1950 2013 Diphtheria 5796 Tetanus 486 Tetanus 486 26 Pertussis 120,718 28,639 Polio 33,300 1* Measles 319,124 187 https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/e/reported-cases.pdf *vaccine-associated 1/4/2016

Complacency 1/4/2016

Convenience 1/4/2016

Convenience 1995: 15 vaccinations protecting against 9 diseases 1/4/2016

Uncertainty 1/4/2016

Uncertainty 1/4/2016

When I hesitate 1/4/2016

Public Health Recommendations from the US Preventive Services Taskforce Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing. All members volunteer their time to serve on the USPSTF, and most are practicing clinicians. Supported by AHRQ to support it 1/4/2016

I am “mammography hesitant” 1 in 9 women who live to be at least 85 years of age will develop breast cancer Mammography detects breast cancer early US Preventive Services Task Force estimates the benefit of mammography in women aged 50-74 years to be a 30% reduction in risk of death from breast cancer. For women aged 40-49 years, the risk of death is decreased by 17%. 1/4/2016

Complacency I’m at “low risk” by family history I’m at “low risk” by lifestyle risk factors 1/4/2016

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Convenience Mammography not done as part of routine health visit; requires special appointment Can be uncomfortable or even painful for some 1/4/2016

Uncertainty Frequent changes to recommendations Disagreement among various medical societies on best practices Potential harms Radiation is scary and does increase risk of some types of cancer Fear of unnecessary biopsies from a false positive result Inability to predict which cancers will progress 1/4/2016

Uncertainty: Mammography 1979 NIH conference: annual screening for women 50 and older; screening for women in their 40s only at high risk 1980s NCI: routine screening for women in their 40s 1989 Eleven health care organizations: initial baseline mammogram for women age 35 to 39, and every one to two years for women over 40. 1992 ACS drops its recommendation for baseline mammography for women 35 to 39. 1993 NCI drops its recommendation for screening in the 40s 1997 NIH conference: not enough evidence to recommend routine screening for women in their 40s. An institute advisory board recommends mammography in the 40s and every 1-2 years. 1997 ACS: annual mammography for all women over 40, and clinical breast exams close to or, preferably, just before the annual mammogram. 2001 A Danish study suggests that mammography’s value may have been overstated. 2002 Independent panel at NCI decides it can no longer make a recommendation on whether women should be screened. NCI stands by its recommendation: women 40 and older should have screening. 2007 Guidelines issued by the ACP acknowledge that regular mammograms for women in their 40s can reduce the risk of dying from breast cancer by a modest amount but false positives common. Women in their 40s and their doctors periodically should evaluate their risk. 2008 A Norwegian study in Archives of Internal Medicine suggests some invasive breast cancers may go away without treatment, ie, may spontaneously regress. 2009 New guidelines in Annals of Internal Medicine recommend that most women start regular breast cancer screening at age 50, not 40, and that women age 50 to 74 should have mammograms less frequently — every two years, rather than every year.

Uncertainty: Mammography Current recommendations from USPHS Task Force: mammography should be every other year for women 50-74 years and starting earlier should be an individual decision; mammography lacks evidence for benefit in women 75 years of age and older. Current recommendations from American Cancer Society: Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. Women age 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening. Screening should continue as long as a woman is in good health and is expected to live 10 more years or longer. All women should be familiar with the known benefits, limitations, and potential harms linked to breast cancer screening. They also should know how their breasts normally look and feel and report any breast changes to a health care provider right away.

Uncertainty: mammography http://doseoptimization.jacr.org/Content/PDF/Hendrick-University.pdf 1/4/2016

When do YOU hesitate? Screening for colon cancer for all at age 50? https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2?ds=1&s=colorectal Daily aspirin for men >45 and women >55 who are at increased risk of heart disease or stroke? https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-for-the-prevention-of-cardiovascular-disease-preventive-medication Annual flu shot? http://www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm?s_cid=rr6505a1_w 1/4/2016

What can help overcome hesitancy? 1/4/2016

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Education: Wake-up Call PEDIATRICS April 2014 1/4/2016

Effective Messages in Vaccine Promotion: A Randomized Trial 1759 parents age 18 years and older residing in the United States who have children in their household age 17 years or younger Parents were randomly assigned to: (1) information explaining the lack of evidence that MMR causes autism from the Centers for Disease Control and Prevention; (2) textual information about the dangers of the diseases prevented by MMR from the Vaccine Information Statement; (3) images of children who have diseases prevented by the MMR vaccine; (4) a dramatic narrative about an infant who almost died of measles from a Centers for Disease Control and Prevention fact sheet; or to a control group. 1/4/2016

Effective Messages in Vaccine Promotion: A Randomized Trial 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 The study authors concluded that their findings emphasize the importance of testing health messages for effectiveness before dissemination 1/4/2016

Effective Messages in Vaccine Promotion: A Randomized Trial Health messages must be tested before dissemination to assess their effectiveness, especially among resistant or skeptical populations. Corrections of misperceptions about controversial issues like vaccines may be counterproductive in some populations. The best response to false beliefs is not necessarily providing correct information. Trying to scare parents with emotive stories could paradoxically increase vaccine safety concerns among those who are already hesitant to immunize. 1/4/2016

If not information from a third party, then what works? 1/4/2016

Thank you! 1/4/2016