>> Kimberly Thompson: Okay, we will get started.
We're missing a few people, but I'm going to assume that they're going to wander in.
And it's -- we do have a packed agenda for the rest of the day, so I think it's probably
better to get started.
I hope that everybody enjoyed their lunch.
And now, we're going to shift over to discussions about opportunity area two related to vaccine
confidence.
I'm very excited to introduce our first speaker, Judy Mendel, who's in the NVPO, who's going
to give us an update on what's happening at the NVPO in terms of their approach to vaccine
confidence and some of the work they've been doing in response to the 2015 NVAC Report
recommendations.
So, over to you.
>> Judith Mendel: Great.
Thanks, Kim.
Hello, everyone.
Good afternoon.
I have to apologize in advance for my raspy voice a bit.
We'll go ahead and get right started.
As Kim mentioned, I'm Judy Mendel.
I'm a health communications specialist at the National Vaccine Program Office, where
I lead and coordinate our efforts around vaccine confidence.
So, this is a bit of a session overview, which I think we'll have a great session.
What we're looking to accomplish here is to provide the committee with an update on efforts
to understand and measure vaccine-related confidence and to strengthen vaccine-related
confidence.
What we'll hear about during this session is I'll present some work on focus groups
that NVPO did with moms who were hesitant about vaccines.
Then, we'll hear from Allison Fisher around CDC's efforts related to vaccine confidence.
Then we'll hear from Rhonda Kropp around measurements through Canada's Childhood National Immunization
Coverage Survey.
We'll then hear from Paula Frew around the development and testing of a vaccine confidence
index.
And lastly, we'll hear from Kathy Edwards on AAP's response to vaccine hesitancy.
So, in my talk, I'm going to talk a little bit about NVAC and the work they have done
around vaccine confidence and try and tie this together.
Then we'll talk a little bit about a vaccine confidence overview.
As I know, we have a lot of new committee members here at this meeting.
We'll try and triangulate some of the terms that are frequently used in this domain.
And then, I will also do -- talk a little bit about NVPO's strategic approach and highlight
the focus group work that we recently did.
So, NVAC guidance.
So, the 2015 recommendations assessing the state of vaccine confidence in the United
States, recommendations from the National Vaccine Advisory Committee, which were unanimously
voted in in 2015 and really made recommendations around the broad focus areas of measurement
and tracking of vaccine confidence, communication and community efforts and strategies, healthcare
provider strategies, policy strategies, and then, of course, continued support and monitoring.
More recently at the last meeting, the February meeting, where the -- where NVAC's report
on the 2010 National Vaccine Plan's mid-course review recommendations were made, and this
was around strengthening -- excuse me -- Opportunity Area 2, which is really what this session
is about, around strengthening confidence in vaccines and immunization system to increase
coverage rates across the lifespan.
And the specific recommendation around vaccine confidence that came out of this report is
that the National Vaccine Program Office should continue to implement the recommendations
from previous NVAC reports, such as the 2015 NVAC report.
By doing so, the NVPO can highlight NVAC recommendations related to implementation -- excuse me -- implementing
the priorities identified in the NVPO 2010 mid-course review.
So, a little bit of background of NVAC's work.
So, in addition to NVAC, of course, who makes recommendations to the Assistant Secretary
for Health, and then our office tries to operationalize and implement what we can around those recommendations.
You know, a lot of others around the table, around the, you know, sphere, around the world
are also -- have either put out statements related to vaccine confidence, hesitancy,
or policy, you know, dedicated specific academic journal articles, publications, lay media,
a lot of other work going on.
Prior to the NVAC 2015 report, the WHO Strategic Advisory Group of experts had a group dedicated
to vaccine hesitancy, and they also put out a report which really goes nicely in step
with the work the NVAC did for that 2015 report.
There's -- some folks probably know Heidi Larson's work out of the U.K., which she's
really trying to take a global perspective on vaccine confidence, as things do differ
country-to-country, low-resource country to higher-resource country, et cetera.
So, a couple terms so we're all talking about the same things and on the same page.
When we're talking about vaccine confidence here, we're talking about the trust parents,
patients, or healthcare providers have in the recommended vaccines themselves; those
who administer the vaccines; and the processes and policies involved in vaccine development,
licensure, manufacturing, and recommendations for use.
We do have to pay attention, though, that there are other definitions of vaccine confidence
that have been used, and some of these -- some examples are having little worry or concern
about a decision or action; holding a strong belief that a certain behavior or doing something
such as getting vaccinated is the best action; or having a strong belief in the safety, value,
and effectiveness of a vaccine.
Couple additional things: so, vaccine confidence is believed to be related to both vaccine
hesitancy as well as vaccine acceptance.
When we're talking about hesitancy, we're referring to the delay or refusal of vaccines,
despite the availability of vaccine services.
And it's a complex and very context-specific thing which varies across domains, time, place,
and vaccines are really not a one-size-fits-all thing.
And we also hear the term "vaccine acceptance" used frequently.
And vaccine acceptance is really characterized around vaccine uptake or coverage and the
adherence to recommended schedule and measured by past behavior and/or the intentions or
willingness to comply in the future.
So, how does this all kind of fit together?
So, it's believed that those with higher levels of confidence are thought to have lower levels
of hesitancy and greater levels of acceptance.
And really, at the end of this, vaccine-related confidence is just one of many factors related
to hesitancy as well as acceptance.
So, a model I like to show, which I think also is a nice level-setting tool, is a model
of the 5As taxonomy for vaccine uptake, which is Thomson, et al.'s work that really looking
across these five A's in a somewhat linear fashion, all of these things have to be met
in order to get to really achieve uptake.
So, that's access, affordability, awareness, acceptance -- and that's really where the
confidence and hesitancy piece plays -- and then ultimately activation, which will hopefully
lead to uptake.
So, our overall rationale for the work.
While we know that childhood vaccination rates in the U.S. are at, near, or above historical
highs, and we know this for even very recent data, ongoing, a couple things we need to
keep in mind, that communities do exist where vaccine rates, vaccination rates, are lower
than desired to really produce adequate protection.
Some parents are delaying or declining some or many vaccines, including because of their
worries or concerns.
And there are pockets of under- or non-immunized people who do have the potential to foster
transmission of vaccine-preventable diseases.
So, with all this considered, it's important to foster confidence in vaccines, those who
administer vaccines, as well as the recommended schedule, which kind of plays into the three
tiers of our definition of vaccine confidence.
So, this flow chart really shows how the approach that NVPO, that's the National Vaccine Program
Office, has taken in trying to work towards both the recommendations set forth by this
committee and kind of the outputs and what we can do as a, really, it's a public health
coordinating office within OASH.
So, in order to foster understanding, advance vaccination, and to really strengthen confidence
through leadership and coordination, and all of the efforts my office is taking on revolve
around collaboration and partnerships, research and evaluation, communication, community provider
strategies, and, of course, dissemination and sharing of knowledge.
So, this is the level set on confidence.
Our -- in those kind of four tenets I just mentioned, the four pieces are fostering collaboration
and partnerships; providing leadership and really scientific leadership where we can;
helping to strengthen, namely, communication and education efforts, materials, and messages;
and then facilitating the identification and visibility of research, which I'm even hoping
that this session today will do some of.
So, now I'm going to talk a little bit about one of our -- and do a bit of a deep dive
in one of the efforts our office conducted, the NVPO conducted, related to confidence.
And these were some focus groups we conducted with moms who were hesitant about childhood
vaccination.
So, the objectives of this qualitative work was to explore vaccine hesitancy among mothers
and female guardians of young children, to obtain a better understanding of what drives
vaccine-related confidence, to gain insights and approaches to build trust and overcome
hesitancy around immunization, and to assess potential value of different messaging approaches
for educating parents and consumers.
So, as I mentioned, these were focus groups.
So, we held eight moderator-led groups, four in the Philadelphia metropolitan area, and
four in the San Francisco area.
We had six to nine women per group for a total of 61 participants.
The groups were held about a year ago in April and May of 2016.
They went about two hours each.
And the way the discussion guide was set up is it went over health concerns, asked about
how these women -- how they internalize confidence, what confidence meant to them.
There were questions related to knowledge, attitudes, beliefs on vaccines and immunization,
and we also shared some educational materials, really educational creative materials, with
them for feedback, and these were shown in the form of videos as well as infographics.
We recruited participants by phone and email, so pretty standard.
In order to be included, a woman had to be 18 years of age or older.
She had to be responsible for the health decisions of at least one child, really 5 years of age
or younger.
And she also had to have a demonstrated level of vaccine hesitancy, and we did use a questionnaire
to assess this.
And more often than not, as part of this questionnaire, participants replied that they had delayed
or declined vaccines specifically.
The groups were made up of women of different races and ethnicities, and we did do some
stratification around socioeconomic status using $75,000 a year as an anchor in terms
of household income.
Those 75 and under were in kind of one set of groups, those 75 and older in another.
So, a couple themes from discussions.
First, around how these women internalized and defined confidence, many women -- and
I think we know this from a lot of the literature -- participants equated confidence to trust,
knowledge, and power.
To them, having confidence meant trusting, feeling good about a decision, knowing that
there were many years of research or practice behind some sort of health or other practice,
feeling that they were informed, and feeling knowledgeable.
On the contrary, lacking confidence meant not trusting, questioning, feeling ill-informed,
feeling skeptical, lacking knowledge, seeing a product not work the way they believe it's
supposed to, or something, unfortunately, causing harm.
So, a couple of our themes in terms of these participant concerns were around ingredients
and physiology, so ingredients in vaccines and how vaccines, in turn, work with the body.
So, there was still an incorrect belief among some participants that there was a link between
vaccines and autism.
Some stated that vaccines are made from weakened pathogens, so there was some level of understanding.
But -- so, weakened pathogens were mentioned in the groups as well and kind of fearing
what does that mean, and is a pathogen, in turn, being put into my child.
There was a belief that vaccines are a replacement for a function that the body's already equipped
to handle.
There were fears of side effects, both near- and short-term side effects, and there were
also very little tolerance for minor reactions: swelling, redness at the injection site, things
that even these women really weren't prepared or willing to handle.
So, a couple quotes we'll see throughout this presentation.
From a woman in Philadelphia, "One of my concerns is the side effects, because there's all these
side effects for all these things.
You don't really ever fully know what the side effects are going to be until they grow
up."
The next theme around concerns is around the immunization schedule.
These women seemed to be more accepting of vaccines that they -- that were on the schedule,
like, when they were children, such as polio was mentioned.
MMR was also mentioned as things they were more comfortable with having their children
be vaccinated.
They didn't understand why vaccinations start so young, and there were some woes spoken
about around, like, the hep B birth dose.
There was a preference for alternative and catch-up schedules.
Some women felt there were too many shots given, while others preferred not to use combination
vaccines at all and preferred to kind of space out and have things done individually.
So, around the schedule, an example of another woman in Philadelphia area: "Everybody's body
chemistry in this room is different, so each child is different.
Putting the same thing in every child doesn't really make sense to me."
So, around participant concerns.
These concerns related to, really, the mainstream medical system.
They felt, some felt, that the dynamic with doctors is different from when they were children.
They didn't like feeling pressured by healthcare providers to vaccinate their child.
They wanted more time to make decisions prior to the point of care, and some women in the
lower SES groups felt that if receiving subsidized or free healthcare services, they felt that
the products in turn that they were receiving must be sub-par.
There also seemed to be a general lack of trust for mainstream medicine and those involved
in the immunization system more broadly.
Couple quotes from the groups: "Then, it's maybe like in the '80s or '90s, when your
family had a doctor and everybody in your family went to the same doctor.
It's way different now."
And that was from a woman in one of our West Coast groups.
Another woman, so in Philadelphia, said, "Don't give me something from the government, because
I know government and pharmaceutical companies are in cahoots together."
So, we're going to move on now and look at some of the messaging approaches and the materials
that were used during the focus groups.
So, the purpose of doing kind of -- looking at messages and looking at these creative
material approaches was to understand how participants reacted to immunization-related
messages and to identify if engagement with any of these materials influence or change
their attitudes about vaccination.
Kind of key immunization-related concepts that were reviewed as videos and printed infographics
were around messages of how vaccines work, herd or community immunity, and vaccine safety.
And how this -- it wasn't particularly rigorous testing, but essentially, the questions that
were asked were on a worksheet with questions around the key messages.
And then, again, the question was asked if the materials changed their level of confidence
at all.
So, this is a quick snapshot of the infographics, and this is going to be very small, so it's
best if you want to take a better look at those to actually pull up the slides and peruse
them at your leisure.
But the first [unintelligible] around how vaccines work, the video -- which we will
watch this video in a second -- kind of demonstrates how a vaccine actually works with the body.
The video around herd immunity, in this case, they did call it herd immunity, not community
immunity, was really a kind of quick-and-dirty whiteboard graphics drawing.
And then, the final video around vaccine safety really talked about anchoring risk, and how
human perception of risk is notoriously inaccurate.
So, while this is a table, please bear in mind that these were focus groups.
This was not particularly, you know, a robust or rigorous process, and this was certainly
qualitative, not quantitative assessment.
But I think this table does do a nice kind of summary job of showing some ideas of what
folks may think they like or what may or may not work.
So, it was clear that the video presentations were certainly preferred over the infographic
presentations of similar material, while, in terms of how informative the women found
the materials to be, they did find them to be fairly informative, and we thought that
was a positive thing.
However, in terms of swaying levels of confidence, it was pretty much middle of the road and
levels of confidence really didn't change.
And granted, they really only interacted with these materials kind of in one set for, you
know, just about a half an hour period of time where materials were being shown.
So, while they liked the videos and did find them informative, there wasn't really any
sort of movement around their levels of vaccine confidence.
So, a couple of things that they did like, which could be potential elements for possibly
effectively communicating.
They seemed to like the presentation of clear messages, and they did think, for example,
that the way information was presented in the video we just saw was pretty clear.
They liked a respectful tone.
One of the videos around kind of the anchoring risk and vaccine safety they felt that some
of the comparisons made or the illustrations used during that video, they found that could
be considered a little bit condescending or even demeaning.
So, they were very -- wanted to feel like they were being respected and spoken to in
a respectful manner.
They did like the use of statistics and details, which these women across the board seemed
to be pretty high information seekers, so that really does align as things that they
would like.
They also had this idea that they wanted information on both the pros and cons of vaccination presented.
However, it's not really clear that even if presenting the risk, it would kind of change
opinions or it is really something that would, in fact, make a difference.
They wanted to think -- they want information to be coming from credible sources.
Now, you know, when we use the word "credible," this means different things to different people.
And of course, you know, their version of credible was everything from peer-reviewed
literature to Facebook posts.
So, it was really a range of what credible really meant to them, and I think those were
all kind of personal feelings.
They also did really like -- so, one of the materials that was shown was the CDC's "Journey
of your Child's Vaccine" infographic, and we actually had participants, out of all the
materials shown, say, "Hey, can we take this one home with us?"
They really liked that and really liked that there were links to additional information
and sources on that particular piece of communication.
So, in conclusion, for these women, confidence entailed trust, knowledge, and control.
Vaccine ingredients, the schedule, and mainstream medical system fostered some concern, and
perceptions of vaccines and immunization were really deeply held and often emotional.
For those of us who are vaccine communicators, what does this mean?
Many sources shape the views and beliefs of these participants.
No single message or approach worked well across the board with all.
Some worked better with certain -- some worked better with others.
And this idea of balanced messages or messages with pros and cons did seem to be desired.
And short videos may have promise and potential, and I think that's mostly because they can
really demonstrate or put things in context in a really engaging way that sometimes print
materials really can't do.
And ultimately, yes, these women and everyone is trying to do the very best for these children,
and I think there are a lot of opportunities for us to help them when making these decisions.
So, thank you, and I think this means Allison's up next.
[applause]
>> Allison Fisher: Good afternoon, everybody.
I'm Allison Fisher.
I'm a health communications specialist at the CDC's National Center for Immunization
and Respiratory Diseases, and I'll be giving an overview of CDC's vaccine [inaudible].
CDC conducts ongoing mixed-method research into the knowledge and attitudes around vaccines
with parents, patients, and healthcare providers.
And that research really informs our understanding and shapes our education and outreach efforts
across the lifespan.
We've done a lot of research in this area and with these audiences in communications
since about 2008, particularly around confidence in vaccine decision making.
Some of the studies that we've done recently are listed here.
I won't go into a lot of detail, but you can see the areas like maternal vaccination, on-time
HPV vaccination, decision making around adult vaccines, and, particularly, surveys with
parents and clinicians around infant vaccination, knowledge, attitudes, and behaviors.
So, today, I'm going to focus on three different studies in that area.
One is a national online poll of parents that we conducted in 2016.
Then I'll talk about a survey we did with some mothers from pregnancy through their
child's early childhood vaccination visits, a longitudinal panel of seven surveys.
I'll talk about some cognitive interviews that we did with vaccine-hesitant parents,
similar to what Judy was talking about with their work at NVPO.
We talked to these parents about some of their informational needs and materials and asked
them to look at some of the things that we had for them.
And then, I'll finish up with some of our general resources and some things that we
have available.
So, first, the national poll of parents.
The goal of this survey really is to help us better understand behaviors, questions,
and concerns around childhood immunization so that we can develop messages, communication
products, and recommendations to help improve vaccine coverage.
We do this by assessing vaccine knowledge, attitudes, and beliefs.
Also talking to parents about their self-reported vaccination behaviors and their plans for
vaccinating their young children.
And we also explore perceptions of healthcare professional communication, that one-on-one
communication with someone's child's physician.
Similar polls were also conducted in 2012 and 2014.
As I mentioned, this is an internet survey.
We surveyed 2,500 parents of kids under age 7.
This was fielded last summer in 2016.
And when we asked them about what they've done at checkups for their youngest child
so far, they mostly self-reported that they were getting their child vaccinated as recommended,
on time.
So, about 86 percent of parents that we surveyed told us that yes, they were getting the vaccines
recommended to them at the time they were recommended.
And about 14 percent of parents told us they were doing something else, including about
8 percent that delayed vaccines in some form.
So, delayed one or more vaccines, delayed all vaccines until later, or some combination
of delaying and refusing or not accepting a vaccine.
I'll talk more about these parents who were delaying vaccines in a minute.
We also asked the parents who said that they had their child vaccinated on time whether
they thought about not getting a vaccine at a visit, but then changed their mind and got
them as recommended.
And about 17 or 18 percent of those parents did tell us that.
So, we kind of called these the hesitant accepters, parents who intended maybe not to accept a
vaccine that was offered, but then did so.
And we asked them about their reasons.
The most commonly-cited reason for changing their mind was their child's doctor or healthcare
professional and those conversations with them.
What we heard from parents who told us they were delaying vaccines for their child is
similar to what we've seen in past surveys and the literature.
In those that were delaying vaccines, we heard flu, hepatitis B birth dose, MMR, and varicella
were those that were most commonly delayed.
Their reasons for delay centered really around side effects, the number of vaccines, as well
as the number of shots.
So, we did try to tease out the difference between the number of vaccines as far as what
a child is receiving, as well as the number of actual shots that a child is getting.
But there was a variety of reasons for delaying and refusing vaccines.
Also, as we often see in the literature, the baby's doctor or healthcare professional was
really the most trusted source of vaccine information among parents, regardless of their
vaccination behavior, although this did really vary by group.
From 98 percent among parents who were accepting vaccines on time to 63 percent among parents
who said they had refused one or more vaccines.
Other trusted sources of information were family members, scientific or medical journals,
and about 24 percent of parents said that they reported the internet as one of their
top three most trusted sources of vaccine information.
Of no -- regardless of what a parent's self-reported behavior was, most parents were using a search
engine.
So, we asked them about the internet, how they were using the internet, what the sites
were.
They were really searching.
They were using search engines to find what they were looking for.
Again, overall, the most common questions and concerns were focused really on short-
and long-term side effects, vaccine ingredients, the number of vaccines and what their potential
impact is on the immune system, as well as general vaccine safety.
About one in five parents were concerned about specific vaccine ingredients, and 17 percent
told us that they still had questions or concerns about vaccines and autism.
Just to note, that group of parents who accepted vaccines but maybe had intended not to, those
hesitant accepters, tended to have concerns across the board that were similar to those
held by parents who were delaying or refusing vaccines.
So, just to conclude the national poll, most parents surveyed really reported accepting
vaccines for their children as recommended.
And some of those parents did consider delaying or refusing vaccine, but discussions with
their healthcare professional, giving more thought to it, and some other reasons made
them decide to vaccinate on time.
Regardless of vaccination acceptance, most parents really did consider their child's
doctor a trusted source of vaccine information.
This is really an important point to stress when we talk a little bit later about some
of the approaches we take in communicating.
The number of vaccines, ingredients, and potential side effects were common concerns, and as
I mentioned, those parents who were hesitant accepters did have questions and concerns
similar to parents who were delaying vaccines, but trusted their child's doctor as a source
in numbers similar to parents who were accepting vaccines.
So, really, it was that interplay of having questions and concerns, trusting the doctor,
that their child's doctor was answering those concerns to their satisfaction, and continuing
on with vaccination.
So, moving onto the next -- the next study, the longitudinal mothers study.
You know, surveys are great.
They offer this really good snapshot of behavior at a point in time, and we use them a lot
to help drive our efforts toward communication and communication topics.
But one weakness of survey, or one limitation of surveys, is something like recall bias
or following people through their decisions rather than asking them about a decision they
may have made several years ago.
So, in an effort to really follow first-time moms through the vaccination process, we really
had this goal for the longitudinal mothers survey to look at moms' knowledge, attitudes,
beliefs, and behaviors throughout the vaccination process, starting in their second trimester
of pregnancy and following through their child's 19th month of life.
Understanding how their attitudes and needs may change over time and identifying how best
to meet those needs, and then identifying any critical decision points in the vaccination
process.
This was a series of seven online surveys that we sent to a panel of 200 pregnant women
who were first-time -- or then first-time moms, beginning in their second trimester,
as I mentioned.
We had 169 participants complete all seven surveys, and these were fielded from 2014
to 2016.
This work was conducted in partnership with NVPO, and we did that in partnership with
them, with their help in developing the surveys and talking through the structure and the
format and how we wanted to gather the information.
And the results from the baseline survey were presented at the September 2015 NVAC meeting.
These results are preliminary.
We're still analyzing a lot of this data.
But I did want to make a few points, because I think it's really helpful, illustrative
data, especially in looking at it along with the survey data.
So, what did the moms plan to do?
What was their plan in self-reported vaccination behavior?
Ninety percent of the moms we talked to in this panel had decided on their vaccine plans
by the baseline survey, so by the survey they took in their second trimester of pregnancy.
And there really was little variation when we looked between planned and actual behavior
over the course of the surveys.
So, if you see in the first column, in the second trimester, about 11 percent said, "I
haven't decided yet," at that point.
"I'm not sure what I'm going to do."
Interestingly, it changed and went up a little bit in the third trimester.
But over the course of the surveys, most moms said they planned to have their child receive
all vaccines as recommended, and most of them told us that they did.
Turning to some issues around knowledge, confidence, and interest in the topic of vaccines.
Interest in vaccines as a topic was really the highest before the baby was born.
We also see this a lot in the literature as well.
There's a high information-seeking period during pregnancy about child health and child
development, and that does include vaccines.
Half reported that they were very interested at baseline.
And even after several vaccine visits, further on in the panel, only about one in five moms
said that they were very satisfied with their current level of knowledge regarding childhood
vaccines, although this was an improvement over the 6 percent we saw at baseline.
So, satisfaction with current level of knowledge around vaccines did go up over the course
of time and experience.
Likewise, confidence in the safety, effectiveness, and value of vaccines was stable during pregnancy,
but then increased over time as children attended their well baby visits.
Looking at communication about vaccines at the actual office visits, the table here is
looking at who they talk to, who parents talk to or who moms told us that they talk to at
the vaccine visit.
And something to note here is that discussion about vaccine questions or concerns was really
the most common at the two-month visit.
That's when the most -- most of the moms told us that they talked to someone, and usually
that someone was the child's doctor.
Not shown here, but satisfaction with vaccine discussions was stable across visits.
About three-quarters of moms said they were somewhat or very satisfied on a five-point
scale with the discussions they were having with their child's doctor.
So, there's some room for improvement, but it was relatively stable over time.
So, what is it we learned so far?
As I said, we're still analyzing this data, but maternal decisions on vaccine acceptance
were almost always being made before a child was born in the moms we talked to.
And they did remain relatively stable over time.
Confidence in vaccines was relatively high, again, but did increase with time and experience,
which is as we'd expect.
Participants really most commonly spoke with their child's doctor about their questions
and concerns, most commonly at the two-month visit.
So, this really, again, emphasizes the importance of direct communication with healthcare professionals.
And yet, we did see some room for improvement in their perceived satisfaction with the discussions
as well as their perceived or self-reported knowledge about vaccines.
So, we know here that opportunities really do exist for partnerships prenatally, with
prenatal care providers and others beyond maternal vaccines and maybe in the realm of
childhood vaccines.
Again, I'll speak to that in just a minute.
Finally, I'm going to talk about some interviews that we did with vaccine-hesitant parents
last fall.
Our goals and objectives were similar to the focus groups that Judy presented earlier.
We were testing CDC messages and materials with vaccine-hesitant parents to get their
thoughts on the messages designed for parents about childhood vaccinations that we currently
offer, examine whether those were meeting their needs, addressing their questions and
concerns, as well as identifying possible improvements.
To do this, we did 24 cognitive interviews.
So, these were structured a little differently than the usual in-depth interview.
Rather than asking a lot of open-ended questions, we were placing materials in front of parents
and then asking them to read them aloud, tell us what they thought, stop if something was
confusing, something they didn't believe, something they particularly liked, and that
was the springboard for further discussion about their vaccination attitudes and knowledge
and decisions for their children.
These were parents or caregivers of children under 2 years of age who expressed hesitancy
toward childhood vaccination.
Again, these included both those hesitant accepting parents who may have gotten all
their child's vaccines on time but indicated a high level of concern or anxiety around
that, as well as those who did tell us that they were delaying or refusing some or all
vaccines -- excuse me, some vaccines or delaying all vaccines.
So, what did we find out?
Their concerns really focused on both the short- and long-term side effects of vaccinations,
similar to what we found in the national poll.
And they were all discussing vaccines with their child's doctor.
In this case, though, some really looked to the internet when they felt their doctor was
"pushing vaccines."
They were really turning to other sources that they trusted and wanted to see for themselves
if what their doctor was telling them was correct.
Some also felt that the child's doctor was withholding information from them, that they
really weren't getting the full story or weren't hearing everything that there was to know
about vaccines.
As I mentioned, most had decided to vaccinate their child, either as hesitant accepters
or with some delay.
Some were delaying about concerns about side effects.
But also something we haven't talked about yet, because their child didn't go to child
care at the time, so they may not have seen vaccine-preventable diseases as a threat or
a threat yet, or concerns, again, over their child being sick at the time of vaccination.
One thing that's also interesting to note is a lot of the participants we talked to,
and again, this is qualitative research, so, you know, keep that in mind as you -- as you
apply the results.
But many parents really weren't aware of the specific vaccines they were delaying.
They just really wanted to slow down the schedule, you know, take them -- take them slower than
they were being recommended.
And when we asked them about what more information they needed about vaccines to feel comfortable,
they wanted to know about disease prevalence, especially locally; repercussions associated
with not vaccinating, so what will happen if we don't; effectiveness; and ingredients.
So, the structure of these interviews.
Parents first looked at one of two print ads, and I know you can see, you know, from the
slides that you get in the back, you may be able to read these a little bit better.
The one on the left with the baby in the bathtub talks about whooping cough, and the one on
the right with the baby learning to walk is about fighting measles.
Then, they looked at one of two more in-depth pieces, either a fact sheet that we have called,
"If You Choose Not to Vaccinate your Child, Understand the Risks and Responsibilities,"
or a draft infographic -- this isn't quite ready yet, but we're still working on it -- "How
Vaccines Strengthen Your Baby's Immune System."
Overall, the parents we talked to really thought the materials were informative.
They were clear and easy to understand, which we like to hear as communicators.
They liked that the images were inclusive and diverse, including the baby learning to
walk with his, presumably, dad or a male -- a male parent.
The materials did increase intention for on-time vaccination for some, if not all participants,
which is what we would hope for and expect.
And they offered us a lot of suggestions for improvement.
The bottom two here, again, really highlight this issue we have of trying to meet our audience
where they are in their informational needs.
They really did want us sometimes to simplify the material, shorten, focus on certain ideas,
as well as include more information -- more graphics, more statistics, give me more information.
So, this is what we -- what we try to balance as communicators in offering information in
different formats and different ways and different levels of interest.
So, in conclusion, on the parent interviews, our participants did want to know more about
the short- and long-term side effects of vaccines as well as the potential consequences of not
vaccinating.
That's something that's addressed in that fact sheet I highlighted there, and I'll talk
about that again in a second.
They were discussing vaccines with their child's doctor, but the trust in the doctor's information
and advice really varied.
And they did like the materials that we -- that we shared with them, so we knew we were on
the right track there.
I'm going to close with some resources, and then next steps about ongoing research.
So, recognizing, again, the importance of the healthcare provider and really the local
variation, potentially, in this, you know, in this topic around vaccine confidence and
hesitancy, we've put together and worked hard on and developed these provider resources
for vaccine conversations with parents.
If you haven't seen, there's some samples on the table in the back if you'd like to
check them out more specifically.
But we developed these with AAP and AAFP, based them on our formative research, and
we review these often.
But it really provides information for physicians to have these conversations one-on-one with
parents, information on vaccine safety, vaccine-preventable diseases, topics of interest that they can
both use themselves, use with colleagues, as well as share with parents.
It includes supplemental resources for parents as well.
We have these in versions, especially the parent resources, for high information-seeking,
maybe more detailed, more dense pieces, as well as more simplified, easier-to-read versions,
and some of those are also in Spanish.
Some of the resources for parents, just to highlight, and you can see the URL there where
you can see those.
These are available to download and use as well.
Things like infographics, the parent-friendly childhood immunization schedule, some social
media-ready pieces as well, in addition to the things like fact sheets and articles and
other formats.
So, again, getting at all the different potential formats and different levels of interest and
information parents are seeking.
I mentioned this one before, and I'll just highlight it as an example.
Again, this is one we tested in the parent IDIs.
"If You Choose Not to Vaccinate."
These, again, were for parents who are considering or have decided to delay or refuse recommended
vaccines, and it specifically discusses the steps to take, maybe before or during an outbreak
of a vaccine-preventable disease to help protect your family and your community, the importance
of notifying healthcare professionals that a child is not fully vaccinated -- especially
healthcare professionals that may not have seen that child before -- as well as considerations
around travel.
But the main message really here is that this is not a risk-free choice.
Making a choice to delay or not accept a recommended vaccine is not a choice without risk, and
it really highlights some of those steps and some of those things that parents need to
be cognizant of if they make that choice.
We also have some resources for maternal vaccination that I wanted to point out.
This is our, you know, set of materials that specifically talks about Tdap and flu vaccination
during pregnancy for both prenatal healthcare professionals as well as pregnant women.
But they also do call up this issue around timing and when pregnant women are looking
for information around vaccines.
One of the sheets, too, the one in the lower right with the mom in the pink shirt, does
have a section about getting moms ready and thinking about their child's vaccines later
in the context of Tdap vaccine protecting their baby when they're born, and then thinking
about protecting their baby with childhood vaccines as they go on.
This is a partnership that's co-branded with AAP, AAFP, ACOG, and ACNM.
And one project that we're working on in our immunization services division is really around
survey questionnaire refinement and development.
I know we're going to talk a little bit about that in some of the other -- the other talks,
but I just wanted to mention it briefly.
We're partnering with NCHS Collaborating Center for Questionnaire Design Research to develop
a series of survey modules that can really assess vaccine acceptance issues in routine
and rapid response surveys as well, doing some methodological research around that now.
And we're hoping to have that final report by the end of the year.
So, just in summary: CDC is routinely conducting this lifespan research and will continue to
explore and apply and evaluate what we learn so that we can better communicate and develop
materials for parents, healthcare professionals, and the general public.
We've learned that parent confidence nationally is high and stable, and does reflect the high
coverage with recommended vaccines that we see in the national immunization survey, but
there are questions and concerns for us to address and for us to support healthcare professionals
in addressing with parents as well.
Likewise, pregnant women that we surveyed were generally supportive of vaccines, and
most had decided on a plan for vaccination before their child's birth.
That really highlights our opportunities for improving the timing of our discussions and
when we're meeting pregnant women with information when they're looking for it.
Parents who are refusing, delaying, or accepting vaccines with hesitation were expressing concerns
again about short- and long-term effects vaccines, and really wanted to know more about the consequences
of not vaccinating their child.
And so, you know, that piece I showed was an example of our attempt to meet that need.
But regardless of behavior, we know parents are discussing these vaccines with their child's
doctor, and so our communication efforts will really work to support healthcare professionals
and parents in those discussions.
[applause]
>> Female Speaker: Thank you very much for running -- just running
speaker-to-speaker.
So Rhonda, as you make your way up, we have your slides up there already.
>> Rhonda Kropp: Great.
Thank you so much.
I know we're a couple minutes behind, so I'll try to go thorough this relatively quickly.
I'm Rhonda Kropp.
I'm the Director General of the National Immunization Program at the Public Health Agency of Canada.
Which, for those of you who may not understand Canada's structure, is one of the agencies
and department that falls under the Federal Minister of Health.
Today we are going to be talking about some of the work that Canada's been doing on trying
to improve our measurement of vaccine confidence, and to Judy's message earlier, the language
is a bit interesting.
Because really what we're looking at is measuring knowledge, attitudes, and beliefs, and linking
those with data on behavior to see where we are in influencing confidence and hesitancy.
In Canada, we do a national survey every two years which is called the CNICS.
And that survey has been done since 1994, and it's been done for all of the routine
childhood immunizations.
The methods for this survey -- and this is a list of the methods from our last one in
2013 -- we use the Canadian child tax benefit for children sampling frame, which is really
fantastic.
It's approximately 96 percent of Canadian children.
And we target the survey towards children age 2, 7, or 17 years, girls age 12 to 14,
and this excludes on-reserve First Nations communities, because there's a different way
to measure for that community.
There's a random sampling stratified done by profits, territory, and age.
And the method is a phone interview with parents and guardians.
And what they're asked to do is pull out their little yellow card.
Doesn't that sound antiquated?
[laughs] Their little yellow card that has all of their vaccinations written down, and
they're then asked to read that to the person on the phone.
For some of the vaccines that are less likely to be recorded on the little yellow card,
such as hep B and HPV, we do accept just recall from the patient -- from the parent, pardon
me.
And then in addition to that, we ask the parent's permission to contact the healthcare provider
to validate what they have told us.
As you can imagine, there's a whole series of places where we then lose people in that
situation, so a portion of them will consent to get this done, a portion of those will
get consent from their healthcare provider, and then a portion of those will actually
contact us.
So, about 30 percent of participants we have confirmatory information from the provider.
The CNICS survey also does knowledge, attitudes, and beliefs data collection, and that really
has the benefit of us looking at what are the knowledge, attitudes, and belief, and
then linking it back to what they've actually had done.
But we really felt that there were some improvements that could be made to the way we do that work.
So, we undertook a project to improve the wording in the questionnaires that we have,
particularly on the knowledge, attitudes, and behaviors component.
We wanted to do a few things.
We wanted to look at the new reporting requirements for vaccine hesitancy under the WHO to make
sure that we're able to report against those.
We also had a group across Canada called the Canadian Vaccine Acceptance and Uptake Task
Group.
They gave us a set of recommendations about a year ago, and it included recommendations
for changing the way we do our measures.
We wanted to respect those recommendations that we got.
And we also took a look at the WHO SAGE Working Group that Judy had mentioned earlier.
So, the first step that we undertook was we created an incredible advisory group, many
of whom you will -- you'll recognize the names on the slide, including Saad, who's sitting
down there and has been warned I might be throwing questions later.
We then took that advisory group and also reviewed evidence before drafting a new set
of questions.
So, again, we looked at SAGE, we looked at our current tool through a health belief model.
We looked at select questions from the core vaccinate hesitance survey, what's proposed
by SAGE, and then we looked at our own survey and recognized that our KAB questions, we
probably needed to get rid of some, could probably keep some but modify them, and that
we were just missing a few things.
So, we went forward with the next step, which was to modify our existing questions and develop
a new set.
So, we made a number of decisions to remove some of our existing questions.
Some of those are listed there.
And where we landed was moving from a set of 35 questions to 42, and only nine of these
actually were maintained from our original set.
So, it's quite a large change to what we're doing.
We have a new set of questions that we've adopted that focus on barriers, that focus
on hesitancy, trusted sources, and sources of information used, all pieces that were
already talked about.
We then did the next step, which was qualitative pretesting.
And this was done through Statistics Canada, our statistics federal agency, who conducted
the survey for us.
They did a total of 29 one-on-one interviews in English and in French.
Canada being bilingual, all of our surveys are delivered in both English and French.
And participants were administered the questionnaire on a face-to-face basis, and they explored
four particular things.
Number one, did they understand the questions and response categories?
Number two, how did they recall search for the requested information?
Is that working?
Number three, did they think about the answer and make a judgment about what to report?
And then the reporting of the answers.
The questions tested very well.
The only questions that didn't work terribly well were perceptions of risk from getting
VPDs.
What we found parents were doing was they just wanted to report back what their child
had been vaccinated against, which is reasonable, because that will influence risk.
But it didn't work as well in this setting.
So, we finalized the questions, and as I mentioned, we landed on 42.
This is just a sampling of them.
If NVAC is interested, we'd be very happy to share all 42 questions that will be going
out into the field.
But a sampling are, "Have you ever decided not to have --" let's use my child's name
-- "Elliott vaccinated with a particular vaccine?
What vaccines did you decide not to give Elliott?
What is the main reason that you decided not to immunize Elliott against" whatever the
vaccine may be, et cetera, et cetera.
So, the next step is going in the field, which we are doing this fall.
So, I'll be very happy to come back to you in a year and be able to report to you on
how these have worked out in the field.
We also, in addition to this work, where we're measuring this, are also funding the Canadian
Immunization Research Network as we have been doing for five years.
We just renewed their funding.
But one difference that we did this year was to earmark a portion of the research funding
specifically to vaccine confidence work in that area.
So, we'll have this survey data this way, we have the funded research through the CIRN,
and I look forward to being able to report back to you all as this goes in the field.
Thank you very much.
[applause]
>> Kimberly Thompson: Okay, thank you very much.
And next, we'll be hearing from Dr. Paula Frew from Emory University.
>> Paula Frew: Okay.
Great.
Thank you very much for the opportunity to be here on behalf of my team.
In 2016, we had an incredible opportunity to join in a cooperative agreement to perform
several tasks in association with NVPO related to the vaccine confidence goals of the organization.
And one of these tasks was really to develop an index that could be useful to gauge changes
in the U.S. parents' confidence over time so that could be used in surveillance and
other applications, as well as for practical clinical applications.
So, that was to develop an index that could be used in clinical settings, either to gauge
an individual's confidence or to assess vaccine confidence over time among individuals in
provider practices.
So, what we did is we undertook a survey with Qualtrics, which is a national panel survey
of parents who are -- have children who are 0 to 7 years old, and we included 893 parents
in our survey.
Now, the survey was developed by our project team, which included our team here from NVPO.
We had some guidance from our vaccine experts.
We also had some biostatisticians on the project.
So -- as well as our internal project team, which was very diverse in terms of our complementary
expertise.
The eligibility that we had set for this project was that we included only parents who -- or
guardians who were -- parents or guardians or caregivers of children who were 0 to 7
years of age, as well as those who were able to read and understand English.
And that was vetted by the Qualtrics team.
We conducted the survey from October through November 2016, and like I said, we actually
aimed for 800 parents, but we ended up oversampling with 893 parents included.
So, the survey was comprehensive.
It included items that pertained to children's vaccination history, so we included nine vaccines
in our survey.
We also included a sociodemographic battery, so we had plenty of sociodemographics, including
parental age, the number of children in household, geographic distribution, and residence location
of our parents, as well as the standard ethnicity, race, and educational components.
But, then what we did is we also looked and we spent a lot of time reviewing the NVAC
report from 2015, and we decided we were going to include the major components from that
NVAC report that included the social norms, attitudes, and beliefs, which included things
like vaccine safety and effectiveness attitudes and beliefs, trust, the environmental -- the
information environment, as well as media, and then provider perceptions.
So, here's how it came out.
So, the sample mean was age 31, and our median was about the same.
It was age 30.
The gender was mostly female that was included, which is somewhat similar to U.S. population
with other factors that we included like ethnicity, race, educational attainment.
But the only thing that we did notice is that the region in which we were a little bit oversampled
was the South.
So, we had 41 percent of the persons in our sample that were from the South.
The children's age composition, we also captured that, but we did report on having the number
of children in household.
So, you can see there's a little bit of a range there in terms of child -- having one
child in the household, so 42 percent of children -- 43 percent in the children in the household
were one child, two children at -- sorry -- at 35 percent, and then three or more children,
22 percent.
So, just in comparison as well, with the ethnicity, we do have perhaps a little bit of oversampling
with our Hispanic population.
The Hispanic population in this country is similar.
White persons, we have a little bit of overrepresentation in terms of 81 percent of persons in our sample
being white, at 74 percent is what is represented in the U.S. census data.
Here's how it was reported in terms of pediatric immunizations.
So, what you can see is that DTaP had the highest coverage, reported coverage.
And what we did is we collapsed those who had reported they did not have the vaccination
or they were unsure of vaccination into one category.
So, for DTaP, you can see that that's 6.7 percent.
Varicella and pneumococcal vaccinations, as you can see, were ranked lowest, and you can
see that pneumococcal vaccination also at 23 percent had the highest unsure or non-response
rate as well as those who were reporting that they had not received the vaccine.
Okay.
So, in terms of our analytic approach, what we did is we had 30 items that we include
in our factor analysis.
Now, the factor analysis included all those attitudes, beliefs, vaccine information, the
trust in government and experts, as well as the social norms that came out of the NVAC
report.
And that resulted in our four-factor solution, with an alpha of .926.
So, that meant that it had a very high reliability in terms of those 30 items holding together
with those four factor facets that we found that corresponded very nicely back to the
NVAC components.
The summary score rubric was developed for VCI based on these 30 items.
And then what we decided to do is go ahead and assess how this relationship looked between
the VCI items, so 30, versus reported vaccination rate.
And then, we ran the logistic models for each of those vaccines, those nine vaccines that
I just stated.
We went through a lot of work to actually whittle this down to something that could
be clinically, practically important to use and something that would not sacrifice a whole
lot of internal consistency and reliability.
So, in the end, we ultimately found that our 30 items held pretty much as well as the final
eight items that we ended up with as our short-form VCI, our index.
So, the index in the end had an alpha of .857.
So, again, strong internal consistency.
And what we found were these are the eight items on a seven-point, five-point, six-point
scale that came out, again, that did not sacrifice a whole lot in terms of our internal consistency.
So, you can see that there are four items in terms of trust on the seven-point scale.
On our six-point scale, we had three items that dealt with confidence, so no confidence
to complete confidence.
And then, we had one point on the agree/disagree Likert scale, and that was around attitudes
for, "It's important to get every one recommended," the vaccines for their children.
Okay.
So, in terms of our specific results.
So, what we did as a next step is we wanted to make sure that the eight-item actually
withstood the tests that we wanted to put that through, similar to what we did with
our 30-item scale.
So, what we ended up with was these four category confidence levels that I mentioned before.
That was our summary scoring system that we came up, based on how well -- how people responded
to those five-, six-, and seven-item scales.
And what we did is we ran the chi-square tests as well as the Cochran-Armitage trend test
to make sure that those items not only compared the self-reported receipt to non-receipt and
were tested, as well as looking at trend tests over time.
What ended up happening from that point is we moved to calculate the odds ratios.
We wanted to look and make sure that we had a very sensitive measure.
Because, again, similar to what you've seen in what Allison just presented in terms of
our high vaccine acceptance and reported rates, as well as what's in the literature, we wanted
to make sure that we had something that was sensitive to the -- to the 10 percent level
to see if there was an odds change in the likelihood of getting vaccination as confidence,
measured confidence, increased as well.
So, we did this for all the nine pediatric vaccines that we assessed, and what we found
was when we did the adjusted odds ratios with -- that included the socioeconomic and sociodemographic
variables that we had in our survey, as well as the crude odds ratios, that it pretty much
came out consistent.
So, what we found was with the eight-item, that also came out as a very robust measure
that we feel had highly-consistent results with the initial 30-item measure.
So, what we have right now is you have very strong correlation between the vaccine receipt
that was reported to us as well as the VCI score, and that increasing VCI score that
we came up with does consistently reflect with statistical significance on all the nine
vaccines, that there was a corresponding increased odds of vaccine receipt.
So, incrementally, as confidence, measured confidence increases, we see the odds also
increasing of them actually having pediatric vaccinations reported for their children.
The short VCI, again, also had very short -- very good internal reliability.
The long-form version of 30 items had a .926 alpha, and then in the end, we had a .857
on the short form.
So, it didn't sacrifice a whole lot in terms of internal consistency by paring this down.
So, we think that ultimately, this works pretty well in both applications.
So, there is a long-form version and a short-form version, and does not sacrifice too much in
terms of what we were looking for to map back to what were the NVAC recommendations.
But we do have some limitations, and of course we do have to address those.
So, one was, obviously, the self-reported vaccination of children, and we know the inherent
limitations of that.
We also know that even though our sample population in this survey was somewhat similar to the
U.S. population, it's not entirely similar, because we do have overrepresentation in the
South.
And so, what we were thinking we need to do for a next step is certainly to move on to
validation.
And that was actually planned in the work that we had proposed.
So, the validation steps now are that we are ready to start testing this in different settings,
so in the clinical research and surveillance settings.
There are plans underway, and in fact, we've just fielded a new survey with a discrete
sample of parents with similar children ages 0 to 7 with another vendor so that we could
have a completely discrete population of parents and retest this with them at this point in
time as well as six months out from now.
So, in the fall, we'll be testing this again.
The other thing is obviously the need for this third-party immunization receipt.
We don't feel like we have -- we have an initial confidence measure, but without that third-party
verification, you know, we understand the limitations of that as well.
The other possibility is that we think we'd like to try and start testing this with other
populations.
So, this could mean that we expand the work that's going on here with parents and move
this to other populations such as college students, pregnant women, elderly adults,
as well as men who have sex with men.
And so, we just again wanted to thank, you know, our staff from Qualtrics who helped
us to implement our survey, as well as Abnica, who is a member of our RSPH School of Public
Health team at Emory University, and Drs. Orrstein and Omer for their advice and guidance
to us.
[applause]
>> Kimberly Thompson: Thank you very much.
So, our last speaker has already prepared to walk up on stage.
And I just want to ask that all of the speakers for this session, please, as Kathy is winding
up, please head up and come back up to the stage to sit in a chair so that we're ready
for the panel discussion at the end.
Thank you very much.
>> Kathryn Edwards: Well, I'd like to present the American Academy
of Pediatrics' response to vaccine hesitancy, and largely this represents a collaboration
between the Committee on Infections Diseases and the Committee on Practice and Ambulatory
Medicine.
So, in September of 2016, the journal "Pediatrics," which is the flagship journal of the Academy,
had three publications that I'm going to survey -- summarize very briefly today.
But the first was an actual survey of pediatricians assessing vaccine delays, refusals, and dismissals.
The second was a collaboration on a clinical report that discussed countering vaccine hesitancy.
And the third was a policy statement discussing medical versus non-medical immunization exemptions.
And these really form a basis for a lot of the thinking that is going on now in the Academy.
So, the first is a survey that was conducted by -- or for pediatricians, and the conclusions
were that pediatricians reported increased vaccine refusal between the initial survey
in 2006 and the repeat survey in 2013.
They perceived that vaccine-refusing parents increasingly believed that immunizations were
unnecessary and that pediatricians continued to provide vaccine education, but are dismissing
patients at higher rates.
So, I'd like to go over the data that substantiates those claims.
First of all, as you can see from the top circle, in 2006, that there were nearly 800
pediatricians that were queried.
In 2013, about the same number.
The practice setting, which is the lower circle, shows that about 18 percent are from solo
or two-practice settings, the majority or a large group are from group or staff health
maintenance organizations, and that there has been somewhat of an increase in hospital
or clinic practices in 2013 as opposed to 2006.
When one looks at refusals that are known -- and the question was, "Are there -- are
you encountering any parents who are refusing vaccines?"
And in 2006, the answer was 74 percent of the pediatricians were including and encountering
parents who had refused vaccines.
In 2013, that number had increased to 87 percent, with a p-value that was significant, as shown
there.
When pediatricians were queried about whether they dismissed patients for continued refusals
in 2006 and 2013, the numbers were in 2006 that about 6.1 percent of the pediatricians
queried would dismiss patients, and in 2013, the number had increased to 11.7 percent.
Which, again, is a significant increase.
When pediatricians were queried about why the patients were no longer -- or were changing
in their attitudes, I think some interesting observations were seen.
The darker colors are 2006, the lighter colors are 2013.
There was really no difference in the cost of vaccines in terms of refusals, and there
actually was less concern about the baby being too small or the discomfort of having vaccinations
or concerns for autism or concerns about the visits.
However, what did seem to be very interesting and significant was that pediatricians were
encountering more parents who said that the vaccines were not necessary.
At this -- in same journal, as I mentioned before, there was a policy statement that
addressed medical versus non-medical immunization exemptions for children -- childcare and school
attendance, and we know that the data do suggest that where there are non-medical exemptions,
there are obviously less children being vaccinated and a risk to those that are vaccinated.
So, given that, the Academy made several recommendations, and I'm going to summarize them on the two
next slides.
First is that the AAP supports laws and regulatory measures that require certificate of immunization
to attend childcare and school as a sound means of providing a safe environment for
attendees and employees of these settings.
Two, that the Academy supports medically-indicated exemptions to specific indications as determined
for each individual student.
Third, the Academy recommends that all states and the District of Columbia use their public
health authorities to eliminate non-medical exemptions from immunization requirements.
Fourth, that the Academy recommends that all childcare centers, schools, and other covered
entities comply with state laws and regulations requiring current and accurate documentation
of appropriate immunization status and appropriate medical exemptions of attendees and students.
And, finally, that the Academy recommends that the appropriate public health authorities
provide the community with information about immunization rates in childcare centers, schools,
and other covered entities and determine whether there are risks to community immunity on the
basis of this information.
Finally, I had the pleasure to work with the other members of the Committee on Infectious
Diseases and the Committee on Practice and Ambulatory Medicine to produce a clinical
report with the -- with the suggestion and specific intent to help pediatricians counter
vaccine hesitancy.
Our overall summaries were that immunizations have led to a significant decrease in the
rates of vaccine-preventable diseases and made a significant impact on the health of
children.
However, some parents express concerns about vaccine safety and about the necessity of
vaccines, and that these concerns of parents range from hesitancy about some vaccinations
to refusal of all vaccines.
And this clinical report was intended to provide information to help pediatricians address
those concerns.
Part of the document highlighted the extensive testing of vaccines before and after licensure,
highlighting the medical need and the disease burden, the scientific feasibility, the basic
science research, the candidate research and manufacturing processes, and preclinical phase
one, two, and three studies.
In addition, the post-licensure assessment was also highlighted with phase four studies
with pharmacovigilance and phase four studies on safety and effectiveness after the time
of registration.
In a figure that was generated in 1996 by Bob Chen talking about the evolution of a
vaccine program, I think it's really important for pediatricians and those of us who deliver
vaccines to understand that, in the pre-vaccine period when the disease is high, people are
very eager to be vaccinated.
But as vaccine coverage goes up and disease declines, people forget about the diseases,
and as adverse events, either related or just simply temporally associated, increase with
the delivery of vaccines, there can be a loss of confidence, can cause outbreaks.
These outbreaks can then remind people of the importance of the disease and resumption
of confidence occurs.
So, I think this dynamic understanding is important for pediatricians to understand,
and we spent some time discussing that.
We also tried to highlight what are the major concerns that parents have about vaccines,
and they really are in three buckets.
First in vaccine safety, capturing too many vaccines, autism, additives, overloading the
immune system, pain, serious adverse events.
Two, the necessity of vaccines, and I think that that really was highlighted on the survey
that I showed you that disease is no longer there, vaccine-preventable diseases have disappeared,
not all vaccines are needed, and vaccines don't work.
So, the necessity is another concern.
And finally, the freedom of choice, for parents to have a right to choose whether they want
to immunize their child, what's best for their child, that there is a lack of trust in organized
medicine, pharmaceutical companies, and other entities which are involved in vaccine manufacture.
We also tried to stress the concern about too many antigens, and in this slide, which
is generated from an article that Paul Offit had written, just suggesting that the number
of immunogenic proteins and polysaccharides has really declined over the years with now
the use of an acellular vaccine as opposed to whole-cell with a lot of other proteins
that you see here.
We spent a lot of time -- initially, we had -- not going to discuss the dismissal of patients.
However, the Academy members, and particularly those from the Practice and Ambulatory Medicine
group, felt that we did need to discuss the dismissal of patients.
And this is the summary of what was done there, that the decision to dismiss a family who
continues to refuse immunization is not one that should be made lightly, nor should it
be made without considering and respecting the reasons for the parents' point of view.
Nevertheless, the individual pediatrician may consider dismissal of families who refuse
vaccination as an acceptable option.
In all practice settings, consistency, transparency, and openness is important.
Finally, the Academy members and the board felt it was very important that we have some
messages that were really integral to how pediatricians should communicate with their
parents.
And those are summarized in these slides that the vaccines are safe and effective; that
serious disease can occur if your children are not vaccinated; that vaccine-hesitant
individuals are a heterogenous group, and their individual concerns should be respected
and addressed; that the vaccines are tested thoroughly and safety nets exist to monitor
safety; non-medical vaccine exemptions increase the rates of unvaccinated children; unvaccinated
children put vaccinated children at risk, and medically exempted children at risk who
live in the same area.
Pediatricians and other healthcare providers play a major role in educating parents about
safety and effectiveness.
Strong provider commitment to vaccination can influence, and as we heard before, does
influence hesitant or resistant parents.
Personalizing the vaccine acceptance is a very effective approach.
The majority of parents accept vaccine providers' recommendations when they are presented as
required to maintain optimal prevention, and the current vaccine schedule is the only one
that is recommended by the CDC and the Academy, and alternative schedules have not been studied.
Thank you very much.
[applause]
>> Kimberly Thompson: Thank you very much to all the speakers for
really excellent presentations for this session.
I would like to now invite the speakers to all please come back up on stage and we will
start the round of questioning.
So, I'll start over with Saad.
>> Male Speaker: So, first of all, a great set of presentations.
And thanks for sort of providing a comprehensive overview of the various efforts that are going
on.
And one thing that, you know, first time we looked at it 15 years ago, it was a little
bit surprising, but it's not surprising anymore, that even parents who refuse vaccines have
high, relatively high trust in their providers.
And that has been a consistent finding for at least 15 years.
But here we are, there are still -- while most parents -- and I think it should be emphasized
that the social norm remains vaccination, but there are gaps in acceptance.
And so, here we are that we -- despite the fact that in observational data, providers
come out as very strong predictors of acceptance, but that hasn't been -- that opportunity hasn't
been fully capitalized.
And to my mind, there are two reasons.
First, there is indeed, or used to be, a dearth of evidence-based interventions from provider-parent
communication.
So, there's a lot of evidence now on, for example, exemptions, et cetera, and mandates
and so on and so forth for interpersonal communication.
There have been development in recent years, [unintelligible]'s work, some of our work,
and other work that has provided cues.
So, that gap has started filling out, you know.
That gap has been -- is beginning to be bridged.
But there's a need to, even in that area, to continue to have evidence-based interventions.
And so, the reason I'm mentioning this, as a committee, perhaps in the future, we could,
you know, as the vaccinate confidence group -- vaccine confidence sort of related activities
of the NVPO progress, maybe there could be a synthesis of this area so that, you know,
various streams can come together.
So, the second thing I would mention is that the second reason for why we haven't, perhaps,
capitalized on the opportunity of providers being almost universally trusted is the fact
we don't know how to communicate to providers.
That's a big black hole of evidence there.
We used to be able to get away with not knowing a lot about it, because AAP and pediatricians
remained deliverers of vaccines in this country, at least.
But as the groups of physicians and providers have expanded who are directly relevant to
vaccines, we need interventions that are not traditional providers.
And even amongst pediatricians, our work has shown that the -- that effect that the availability
heuristic that Dr. Edwards showed about sort of decreasing rates of disease versus real
and perceived adverse events, that -- we tested that hypothesis amongst physicians, and unfortunately
in pediatricians and family practitioners, while there's high support for vaccines, but
the year of graduation predicts how gung-ho they are about vaccines.
So, we cannot take this thing for granted.
And I think -- and as a future-looking set of activities that are undertaken as part
of vaccine confidence by different partners as coordinated by NVPO, I think that's an
area, that that's a gap that needs to be filled where we develop evidence in terms of communicating
to providers.
The third thing I will -- I would mention, that there was a trend in terms of more pediatricians
dismissing -- you know, a high number of pediatricians dismissing parents.
While I can understand the frustration in the clinic if you have had repeated encounters
and an outbreak setting -- specifically an outbreak setting, but I don't buy the argument
in terms of non-outbreak settings -- the risk in the waiting rooms goes up for other patients.
But I think we should step back and recognize that if yelling at parents were a good idea,
teenagers would have been the most effective communicators.
So, a more sort of respectful approach that falls way short of dismissing parents and
not making them cluster, conversely, in practices that are more sympathetic, is more productive.
And so, that was a comment.
>> Female Speaker: I'll offer the opportunity for any other panel
members to respond to the comment if they like.
Otherwise, we'll go to the next question.
>> Rhonda Kropp: Thank you very much.
Saad, I couldn't agree with you more, and when we received some budget funds when we
got our new government in 2016 for immunization, one of the first things we did was acknowledge
exactly that.
So, I'm really glad you brought it up.
We created an immunization partnership fund, and the first stream of call-outs that we
did was related to supporting healthcare providers, related interventions.
And in addition to that, we decided to partner with a number of organizations whom providers
trust and respect more than us, quite frankly, and that was in recognition that a provider
is not a provider is not a provider.
Our midwives have different issues than our pediatricians than our obstetricians, gynecologists,
family medicine -- it's all different.
So, we partnered with a number of different organizations across Canada who have the respect
of those -- of those provider groups, and have provided funding to do exactly what you're
saying.
We know that that's the most trusted, and we know that we, federally, within Canada,
we are not the people that they are listening to.
It's those providers.
So, we have focused a ton of energy in exactly that area, and I'll look forward to being
able to report back to that in the next couple years after the interventions are put in place.
>> Kathryn Edwards: I think that I wanted to comment just a little
bit about educational endeavors, because we did send out a survey to -- both to OB and
to pediatricians in terms of education about vaccines and vaccine safety, and about the
disease.
And I think that in medical school, we may not be teaching as many people as we should
about the diseases.
I think it's also very clear those of us who are longer of tooth do remember the diseases
a lot better.
I remember the night I was -- my last as an intern, I watched a child with H. flu B die,
and will never forget the impact of that disease.
But not seeing those diseases -- so I do feel that we do need to teach our physicians, our
young physicians, what vaccine-preventable diseases mean and how we have changed the
scope of diseases that we take care of.
And certainly, I think that's very important as well.
Refusal is very complicated, and I think it's very hard to know how to respond, and I think
that there were many different views.
I think that the practicing pediatrician has a lot of struggles with this, and I think
that I'm not sure -- I think you have to decide yourself what you're going to do with the
parents in that regard as well.
>> Kimberly Thompson: Okay, Melissa?
>> Female Speaker: Thank you.
As somebody that's been trying to talk patients or parents into doing vaccines for 30 years,
I can tell you, it's a very humbling process, that there's certainly -- I used to think
that if I just presented all of the facts, all of the science, that people wouldn't refuse.
But what I've found is that there are some patients that just want a little bit more
information, and they're fine.
But there -- for a lot of patients, vaccine acceptance is not a factual issue.
It's an emotional issue.
And whatever facts I give them, they're going to look on the internet and find facts to
counter that.
So, to me, the important thing about getting people who are hesitant to change, and I think
-- I thank you for your talks, because I think it reinforced a lot of what I've found, is
that it is emotional issue, that it takes a relationship over time to change things.
So, dismissing people isn't a good idea.
That sometimes people -- I know there's a lot of facts that patients rely on physicians,
but the truth of the matter is, some of my most successful conversions have come from
a community health worker who looks more like the patient than I do talking to the patient,
or from a medical assistant.
So, I think sometimes, when I'm dealing with somebody who doesn't want to accept a vaccine,
I think of it more sort of we do -- like we do quitting -- getting somebody to quit smoking.
If I just move them to smoking a few less cigarettes, I feel like I made a mistake.
One of the problems that I see is that quality indicators don't allow for that gradual movement.
It's either black or white.
Did they get the immunization, or did they not get the immunization?
And I can understand how people whose compensation is being based on quality indicators would
want to not have patients that are -- that you're having to work with and move over time,
because you don't have those black-and-white indicators.
So, I guess I don't have an actual question.
That's just my comments.
>> Kimberly Thompson: All right.
Let me ask, does anybody want to respond?
Not?
Okay.
So, then I will go to David.
>> Male Speaker: Thanks.
I'm trying to think how to ask this without sounding foolish.
But I guess maybe in follow-up to the last comment, I'm wondering -- I'd like the panel
to think about, are we doing the wrong thing by making this problem more simple than it
is and thinking about it as a rational, medical problem?
My experience in public health practice has been that when I talk about vaccine hesitancy,
people have told me that's a common word, but that's actually not a common cause.
And that's a final common pathway around -- which people get there through many different ways,
and unless, when you're working with people, you begin to analyze the upstream nature of
how they got there, you're probably not going to be successful in changing their minds.
It's also not an issue that's necessarily influenced or influenceable by talking about
vaccines and vaccine knowledge and vaccine attitudes.
It may be that a person's political or worldview or religion is actually the primary determinant
here that is creating those attitudes, and until you begin to talk with them about some
of those upstream issues, you're not going to get very far.
And then lastly, and I can speak from this from personal experience, it may not be an
individual issue.
It may be a community issue.
In several of the places, two of the places I've worked, Santa Fe and Seattle, we had
communities of well-educated, affluent, liberal, rural whites where immunization refusal rates
were among the highest in those jurisdictions.
And that was a very strong community-held value in those places that merely trying to
talk individually, one-on-one with those parents, did not get us very far.
Going and talking with the community didn't get us very far, either, but at least we felt
that we being more rational in our approach.
So, I guess at the bottom line, my question is, do we need to be expanding our notion
of what we're thinking about interventions based on causes rather than thinking that
a standardized medical explanation of the risks and benefits of immunizations is going
to carry the day?
>> Female Speaker: Okay.
It's complicated.
I think some of you already said that one size doesn't fit all here.
Does anybody want to respond?
>> Judith Mendel: I think that's -- I think that's correct,
and I think we need to -- sure, we need to continue to understand what may be driving
and facilitating, whether it's a cultural thing, a political thing, whatever it may
be.
We need to do that simultaneously to also kind of understanding and assessing it in
the kind of medical setting.
I think we need to continue to come from a really multi-pronged, multifaceted approach,
and I hope that's what we're going to continue to be able to do.
>> Rhonda Kropp: The only other comment I would make is from
our perspective, there's a whole number of priorities that we're working on.
At the end of the day, what we want is to ensure that we have appropriate vaccination
coverage at a national level and within our subpopulations.
Only a small portion of those are really people who aren't getting vaccinated because they
have a fundamental concern about vaccines.
And a small portion of those are ones that we are unlikely, even if we get down to the
core, to change that.
If I'm looking realistically at what's going on, at least in my country, there's a big
chunk of folks who may be hesitant, but they're still getting their children vaccinated.
And then, there's another chunk of folks who are not hesitant, but aren't getting vaccinated
because they're complacent.
So, where do I put my resources and my energy?
I know that in my own group, I have 100 employees.
And when the Ottawa public school system sent out letters this year to say kids were going
to start getting kicked out of school, they didn't have their vaccines up to date -- this
is my immunization group -- I swear, half of the parents in my -- in my own group were
not up to date.
These are people who know.
So, for me, there's a question of how many -- with many competing priorities, how much
energy, how many resources do we put towards the hardest of the hardest of the hardest
to shift them, versus looking at where we may actually have an influence?
>> Allison Fisher: I think just quickly related to that, you
did bring up the point of local versus national.
I think that's something to reiterate and reinforce that this is something that is addressed
by us working at the national level, but also with partners that know their local communities,
know the specific issues, and are trusted resources there.
>> Kimberly Thompson: Okay, Mary Anne.
>> Female Speaker: Thank you very much.
Kathy and Rhonda were starting into this area, I think, but I want to talk a little bit -- the
panel to talk a little bit more about knowledge, attitudes, and behaviors of practitioners
in terms of how well they can -- what their knowledge base is, how well they can answer
questions, and Kathy, you alluded to medical students.
But pediatric residents and family practice residents probably spend literally hours with
the curriculum on vaccine safety.
And what is our responsibility there, and how important is that?
>> Kathryn Edwards: I think that we do need to more systematically
explain the process of vaccine testing, the concepts of what we do for safety.
I think that many, you know, many students don't understand what VAERS is or how to report
adverse events, and so I think that there does need to be a lot more role-playing and
actually interacting with different questions and perhaps more model patients would be helpful
to discuss some of these issues.
So, I think that there's a lot that needs to be done, and certainly, there are studies
which suggest that the younger physicians are less comfortable talking about these issues
than the older ones.
And so, I think that that is important as well.
So, I think there do need to be educational efforts and ways to address this, and certainly,
as Saad said, there needs to be more research.
There needs to be better ways to present vaccines to patients, and certainly there are studies
that show that just trying to talk people out of their attitudes don't work.
And so, the whole communication process, I think, really needs a lot more work.
But I think it also needs to start with just basic vaccine 101, which I don't know that
is getting taught in, maybe in pharmacy schools or nursing schools, I don't know as well,
but certainly the surveys of the medical schools and residency programs probably are not as
thorough in terms of the teaching that's needed as well.
>> Rhonda Kropp: And as if you set that up perfectly for what
I was about to say, we have the same issue in Canada.
And a concrete example of that was there's a program in Canada that is vaccines 101 and
vaccination 101 called EPIC.
And we -- it's delivered by the Canadian Pediatric Society and funded in part by my organization,
and EPIC is currently on hold because of an issue with an online delivery mechanism.
Anyways, it will come back on at some point, most likely.
But the outcry that we received from nursing groups, pharmacy groups, physician groups,
because they felt that this was really the only way that that core vaccine and vaccinology
information was actually getting to those practitioners was really stunning.
So, we have a really strong feeling that we need to be working a little bit more with
licensing bodies, with schools, to figure out how we have gotten to a point where an
external program, which is not guaranteed to stay in place forever, is now the core
source of information for a large portion of our practitioners in Canada.
>> Kimberly Thompson: Great.
Thank you.
Okay.
Leonard?
>> Male Speaker: This is a perfect lead-in for what I was going
to reinforce as well and ask that our committee think about.
The healthcare provider is really quite broad, that patients and parents interact with.
They're nurses, they're midwives, they're pharmacists, they're pediatricians, they're
healthcare extenders, the aides, the internists, the geriatricians.
There's a wide group of people who interact with patients, even from when the family walks
into the office, the person they see at the front desk.
So, I would ask our committee to think about, as we look to making recommendations, to put
education emphasis, however we're going to educate, on this wide swath of healthcare
providers and not just focus in on what we consider the doctor in that exercise.
>> Kimberly Thompson: Thank you.
Did anybody want to comment?
Or I think that was really just a comment.
So I'm going to move on.
Larry?
>> Male Speaker: Those of us at this end of the table in our
little corner noticed there's something distinctly missing from the people on the stage.
>> Female Speaker: [unintelligible]
[laughter]
>> Male Speaker: Which leads me to my first question, and that
is that we're all products of our environment and our experience.
In the surveys that have been done, is there anything that stands out in refusers?
In other words, a mother who may have one versus two or three children, the fact that
the parents aren't being immunized themselves, or the age of the mother?
Is there anything that stands out, or are the numbers not large enough to really determine
that?
>> Allison Fisher: Is this on?
Okay, good.
The maternal vaccination work that I've done, we have seen some characteristics of refusers.
It's actually a little uncertain, still.
I think the science is not quite, you know, where it needs to be to make anything that's,
you know, an absolute conclusion at this point.
But we are seeing some trends in terms of refusal being linked to, like, in my case,
I've measured flu vaccine, so non-receipt of flu vaccine, so not having them hooked
in, if you will, to that behavioral continuum is definitely a problem.
And, you know, the through-line to that is, you know, I've actually measured what is the
likelihood of the child, you know, once born, being immunized after six months.
And it's not good.
So, I think if we can back it up to, you know, what we're doing in terms of maternal vaccination
and trying to work with pregnant women, that has an awful lot of promise for that trajectory
of moving them towards immunizing children in the future.
So, as far as, you know, racial, ethnic, you know, other sociodemographic characteristics,
it's still not conclusive.
You know, I have seen refusal higher with African-American women who, you know, when
we're asking them specifically about flu vaccine, that that is higher than other groups.
But again, that's just one study, so a little reluctant to say that that's, you know, much
evidence to go on.
But at least you do see a little bit there.
But I think the biggest -- the biggest indicator so far is parental non-receipt of vaccination.
So, that does seem to come out as something that may have a little bit stronger evidence
at this point.
>> Kimberly Thompson: Okay.
Thank you.
We're bumping up against the time, but I'm going to take the last four questions.
I'll ask people to be brief.
The first one is Robert, then Cody, then John, then Melody.
Robert?
>> Male Speaker: So, just to go back to one of your first comments,
Ms. Mendel, people are looking at search engines.
We didn't mention social media, but both of those are places that commonly get attacked
or looked at by people that are not of our ilk when we think about vaccine information.
And so we can't forget the importance of some of those pieces of "information," as opposed
to mal-information and their impact on patients and families.
The other piece that's important to recognize is that our messaging for vaccine refusal
or objection or complacency, whatever the issue may be, very well may not be the same
for adults and adult vaccines as for childhood vaccines.
And finally, remember that we have good data from our friends at the CDC that there are
much greater racial and ethnic disparities amongst adult vaccination across our nation
than there are for childhood.
>> Kimberly Thompson: Quick response, or--
>> Judith Mendel: Sure.
>> Female Speaker: Okay.
>> Judith Mendel: So the social media piece, yes, of course,
and even when I was mentioning that piece about credible source, and kind of made the
point that we don't -- what each of us considers a credible source may differ.
So, we know, and we're well aware of kind of the various sources that feed into people's
beliefs.
And thank you for plugging adult immunization.
NVPO, of course, adult immunization is one of our priority areas, and we are looking
to do more work that kind of marries the adult space with some of this confidence work, because
really more work is certainly needed around adults.
>> Kimberly Thompson: Okay.
Cody?
>> Male Speaker: Thank you.
I'd just like to take another perspective.
In the sense that the pediatricians are getting beat up a little bit, and I don't think there's
a shortage of understanding among pediatricians regarding the importance of vaccines and immunizations.
And they're certainly, there are some, we know, who are not vigorously supporting the
importance, but I think that's a distinct minority.
And I was struck by an editorial earlier this year in the Journal of the American Medical
-- the JAMA, and this commentary linked eligibility to welfare and benefit payments to the vaccination
status of the children.
And this is -- Australia has been doing this for 20 years, and it has turned out to be
quite successful.
Now, you get into an interesting discussion about the ethics of this, but you can argue
the ethics both ways.
I mean, you can say it's not -- may not be appropriate to force parents to vaccinate
their children if they don't want to, but then on the other hand, is it fair for those
children who are born into families and they don't get vaccinated?
So, I think rather than -- or one option to just more education, more discussion with
families, is that there needs to be a little bit of incentive.
Listen, this is part of being a member of the community.
We vaccinate children for two reasons: one, to protect the child, and secondly, to protect
the community.
And the courts have supported this over the years.
So, just a comment.
>> Female Speaker: Yeah, okay, thanks for the comment.
I think because of the importance of the VFC program, I'll hand it to Nancy just for a
second to respond to that point.
>> Female Speaker: I'm not responding to that point.
[laughter]
>> Female Speaker: But I -- but I -- in the first part of what
you said, I mean, I actually also want to sort of give a call-out that pediatricians
are by and large, 99.9 percent of them, incredibly committed to vaccination.
And I think one of the things I hope that Allison's research pointed out is that part
of the equation actually comes before pediatricians, and that's a segment that I don't think, you
know, the OB/GYNs don't think of themselves as being the springboard towards pediatric
vaccination.
And that role of turning OB/GYNs not only to vaccinators, to get flu and Tdap vaccine
into pregnant women, but also to make them feel the responsibility of setting the stage
for pediatric vaccines, that's something that we really haven't faced yet and surmounted.
Pediatricians, you know, many of you know, I also still have young kids, so I mean, I
feel the burden of the pediatrician.
And in the segmenting of the population of parents' perceptions around vaccines, there
are people that are -- don't need anything.
There are people who are hesitant accepters, and a little bit of energy will change their
mind.
It's a very small segment of the population that are truly skeptical of vaccines.
And I understand a pediatrician's perspective in the limited amount of time and energy they
have, they have to make a choice as to where they spend their time.
I think, I mean, back to this question of what, you know, NVAC could do, I would go
back to something that Dave sort of started with, which is, you know, as much as we want
nationally to have a solution to this or national research that's going to provide guidance,
the problems are incredibly local.
And so, somebody asked about the epidemiology of vaccine refusals, but it looks pretty different
in Minnesota than it does in Oregon or any place else.
And so, I think it makes it really hard to have national strategies when in the end it
really is about a local conversation, either pediatrician to patient, or somebody who is
culturally competent speaking to their own population.
And it's hard to do research at a level of which is going to encompass every single one
of those conversations.
We can focus, as we have, on tools for providers and trying to give them the tools that they
need for each kind of interactions, but it's really hard to get down to a granular enough
level that we can actually face every single parent-provider interaction.
And I would just also point out, back to something that I said last time, that this is a really
important issue.
We take it really seriously.
We believe in the research base to do it.
But I would also remind you, as somebody said, that, you know, if you look nationally, less
than one percent of kids get no vaccines.
We're very, you know, it's important to us to keep that.
But there are other discrepancies around pediatric vaccination coverage, like socioeconomic status,
that really shouldn't be a barrier because there is VFC, and vaccines should be covered.
And yet, there are people who aren't getting access to vaccines of lower socioeconomic
status in the pediatric population.
And so, this is an important issue.
It is the one issue, and there are others.
>> Kimberly Thompson: John?
>> Male Speaker: I'll be very brief.
Most of what I wanted to say and ask has been very eloquently put forward already.
Just to expand on what you said, even beyond -- even beyond OB providers, et cetera, what
I took away from some of the data that you showed up there was that even by the second
trimester, the horse is already out of the barn.
I would encourage us as a committee and people who do work in research to think even broader
about non-traditional messengers and non-traditional platforms for this.
And by non-traditional messengers, I'm not even just talking OB providers.
I mean adult care providers.
Have people before people are ever pregnant talking about kids' vaccines, and people who
are non-medical providers, educators other -- examples are endless.
The points -- the point in general is I think -- I think we need to be really thinking about
a different paradigm for this.
>> Kimberly Thompson: And last question, Melody?
>> Melody Butler: I'd like to take some of the burden off the
pediatricians, and I'd like to bring the nurses to the table.
And I'd like to know where they are in helping to promote these vaccinations.
As much as you guys may try as doctors and, you know, practitioners, at the end of the
day, it's the nurse who's going to administer the vaccine.
And it's important that the nurse is giving it to them isn't giving, you know, that weird
side eye, saying, "I wouldn't give it to my child."
And we know this has happened.
I am -- as the leader of Nurses Who Vaccinate, I come in contact with nurses every single
day who are not confidently encouraging the vaccination among their patients and communities.
This is an ongoing problem, and we cannot forget about the elephant in the room.
So, I implore the committee to please look at the relationship between the vaccine confidence
in the nursing population and the nursing schools and to really make an effort to really
bring forward why this is happening in the first place.
Why are college-educated practitioners even doubting the science?
And bring them to task and really kind of, you know, open the door to improving confidence
among nurses.
Thank you.
>> Kimberly Thompson: Okay, thank you.
I think we are all set.
I want to thank our outstanding panel and all the speakers and questions.
I apologize for not getting to all of the questions.
I know somebody wanted to speak again, but I do want to move on with the time.
We will reconvene in 15 minutes.
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