Applied Evidence

When the answer to vaccines is “No”

J Fam Pract. 2018 June;67(6):348-351,359-364

From The Journal of Family Practice | 2018;67(6):348-351,359-364.

References

1. Paterson P, Meurice F, Stanberry LR, et al. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34:6700-6706.

2. Opel DJ, Heritage J, Taylor J, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1037-1046.

3. Palmer J, Carrico C, Costanzo C. Identifying and overcoming perceived barriers of providers towards vaccination: a literature review. J Vaccines. 2015;1-7.

4. Autism Science Foundation. Making the CASE for vaccines: a new model for talking to patients about vaccines. Available at: http://autismsciencefoundation.org/wp-content/uploads/2015/12/Making-the-CASE-for-Vaccines-Guide_final.pdf. Accessed April 8, 2018.

5. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E approach: guidance for talking to vaccine-hesitant patients. Minn Med. 2013;96:49-50.

6. Henrickson NB, Opel DJ, Grothaus L, et al. Physician communication training and parental vaccine hesitancy: a randomized trial. Pediatrics. 2015;136:70-79.

7. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. Available at: https://www.cdc.gov/flu/protect/keyfacts.htm. Accessed April 8, 2018.

8. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.

9. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32:3623-3629.

10. Agency for Toxic Substances & Disease Registry. Minimal risk levels for hazardous substances. Available at: https://www.atsdr.cdc.gov/mrls/mrllist.asp#34tag. Accessed April 8, 2018.

11. US Food and Drug Administration. Thimerosal and vaccines. Available at: https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228. Accessed April 8, 2018.

12. Hviid A, Stellfeld M, Wohlfahrt J, et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003;290:1763-1766.

13. Centers for Disease Control and Prevention. Thimerosal in vaccines. Available at: https://www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html. Accessed May 8, 2018.

14. Autism Speaks. Frequently asked questions. Available at: https://www.autismspeaks.org/what-autism/faq. Accessed April 8, 2018.

15. Agency for Toxic Substances & Disease Registry. Toxic substances portal-aluminum. Public Health Statement for Aluminum, CAS #7429-90-5. Available at: https://www.atsdr.cdc.gov/PHS/PHS.asp?id=1076&tid=34. Accessed April 8, 2018.

16. Children’s Hospital of Philadelphia. Vaccine ingredients-aluminum. Available at: www.chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/aluminum. Accessed April 8, 2018.

17. Orenstein W, Seib K. Mounting a good offense against measles. N Engl J Med. 2014;371:1661-1663.

18. Plans-Rubió P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med. 2012;55:72-77.

19. Hall V, Banerjee E, Kenyon C, et al. Measles outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:713-717.

20. The National Academies of Sciences Engineering Medicine. History of U.S. water and wastewater systems. Privatization of Water Services in the United States: an Assessment of Issues and Experience. Washington, DC: The National Academies Press; 2002:29-40. Available at: https://www.nap.edu/read/10135/chapter/4#35. Accessed May 7, 2018.

21. World Health Organization. Global vaccine safety. Six common misconceptions about immunization. Available at: http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index1.html. Accessed May 7, 2018.

22. The history of vaccines. Human cell strains in vaccine development. Available at: https://www.historyofvaccines.org/content/articles/human-cell-strains-vaccine-development. Accessed April 8, 2018.

23. The National Catholic Bioethics Center. Frequently asked questions. Available at: https://www.ncbcenter.org/resources/frequently-asked-questions/use-vaccines/. Accessed April 8, 2018.

24. Shimabukuro TT, Nguyen M, Martin D, et al. Safety monitoring in the vaccine adverse event reporting system (VAERS). Vaccine. 2015;33:4398-4405.

25. Foster S. Rotavirus vaccine and intussusception. J Pediatr Pharmacol Ther. 2007;12:4-7.

26. Mistry RD, Fischer JB, Prasad PA, et al. Severe complications of influenza-like illnesses. Pediatrics. 2014;134:e684-e690.

27. McNeil MM, Weintraub ES, Duffy J, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol. 2016;137:868-878.

28. McLaughlin JM, McGinnis JJ, Tan L, et al. Estimated human and economic burden of four major adult vaccine-preventable diseases in the United States, 2013. J Prim Prev. 2015;36:259-273.

29. Centers for Disease Control and Prevention. Vaccines for Children (VFC) Program. Available at: https://www.cdc.gov/features/vfcprogram/index.html. Accessed April 8, 2018.

30. Plotkin S, Gerber JS, Offit PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis. 2009;48:456-461.

31. Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-129.

32. Offit PA, Moser CA. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics. 2009;123:e164-e169.

33. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2016-17 influenza season. Available at: https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm. April 8. 2018.

34. Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state and selected local area vaccination coverage among adolescents aged 13-17 years – United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882.

35. Thomas TL. Cancer prevention: HPV vaccination. Semin Oncol Nurs. 2016:32:273-280.

36. Centers for Disease Control and Prevention. Estimating seasonal influenza-associated deaths in the United States. Available at: https://www.cdc.gov/flu/about/disease/US_flu-related_deaths.htm. Accessed May 8, 2018.

37. Wong KK, Jain S, Blanton L, et al. Influenza-associated pediatric deaths in the United States: 2004-2012. Pediatrics. 2013;132:796-804.

38. Centers for Disease Control and Prevention. Seasonal influenza vaccine effectiveness, 2005-2018. Available at: https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm. Accessed April 8, 2018.

39. Centers for Disease Control and Prevention. Influenza (flu). Flu vaccine and people with egg allergies. Available at: https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Accessed April 8, 2018.

40. Centers for Disease Control and Prevention. For parents: vaccines for your children. HPV vaccine for preteens and teens. Available at: https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html. Accessed April 8, 2018.

41. Centers for Disease Control and Prevention. Vaccines and preventable diseases. HPV vaccine recommendations. Available at: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed May 7, 2018.

42. Cutts FT, Franceschi S, Goldie S, et al. Human papillomavirus and HPV vaccines: a review. Bull World Health Organ. 2007;85:719-726.

43. De Vincenzo R, Conte C, Ricci C, et al. Long-term efficacy and safety of human papillomavirus vaccination. Int J Womens Health. 2014;6:999-1010.

44. McInerney KA, Hatch EE, Wesselink AK. The effect of vaccination against human papillomavirus on fecundability. Paedeatr Perinat Epidemiol. 2017;31:531-536.

45. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271:193-203.

46. Vichnin M, Bonanni P, Klein NP, et al. An overview of quadrivalent human papillomavirus vaccine safety: 2006-2015. Ped Infect Dis J. 2015;34:983-991.

47. Bednarczyk RA, Davis R, Ault K, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11-to-12-year-olds. Pediatrics. 2012;130:798-805.

Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).³ In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.”^4-7)

SIDEBAR
Facilitate vaccine discussions using these 2 approaches^4-7

C.A.S.E.

Corroborate
Acknowledge concerns and find some point on which you can agree.

Example: "It sounds like we both want to keep your child healthy and safe."

About me
Describe what you have done to build your expertise on the subject.

Example: "I have been practicing medicine for 15 years and have spent a great deal of time researching the data on vaccinations."

Science
Review the data and science behind vaccines.

Example: "Vaccines are more rigorously studied and safer than almost any other intervention we have in medicine."

Explain/advise
Explain your recommendations, based on the science.

Example: "This is why I vaccinate my children, and this is why I recommend this vaccine for your child."

3As

Ask
Don't stop at a patient's first "No." Respectfully dig a bit deeper.

Example: "What questions do you have about the vaccines we are recommending today? Tell me what worries you about them."

Acknowledge
Acknowledge your patient's concerns.

Example: "You are obviously a very devoted parent, and I know that you are trying to make the best decision you can for your child. With everything we see on the news and social media, it's not always easy to know what to believe about vaccines."

Advise
Advise patients/parents of the facts about vaccines and provide a strong recommendation to vaccinate.

Example: "Depending on the year, influenza kills 12,000 to 56,000 people annually; the vast majority of those who die did not receive the flu vaccine.⁷My family and I get the flu shot every year, and I strongly encourage you and your children to get this lifesaving vaccine."

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