ApproachingtheVaccine

HesitantParentusingCASE
RobertMJacobson,MD,FAAP
ProfessorofPediatrics,MayoClinic

Disclosures
Potentialconflict
PrincipalInvestigator
AdultPCV13Prevnar13vaccine(Pfizer)
MenveoMCV4vaccine(Novartis)

SafetyReviewCommitteeMember
GardasilHPV4vaccine(Merck)

DataandSafetyMonitoringBoardMember
15valentPCV(Merck)

Noofflabelusediscussion

LearningObjectives
Relateanewapproachtovaccinehesitancy
Identifyeachofits4components
Describehowitworksin3commonscenarios

TheStateofVaccination
Theantivaccinemovementisthriving
Successfulvaccinationmakesitsvalueinvisible
Mediaseekstoportraycontroversy,bothsides
Americansculturallyopposedtopublichealth

Vaccinehesitancymajorissue
Notjustamongexemptorsanddelayers
Even25to30%ofthoseuptodate

Educationorinformationtransferinsufficient
Bothclinicianandparentstruggle

TheClinicianintheOffice

Haslittletimefordiscussion
Suffersasenseofrejectionaswiseadvisor
Feelssenseoffutility
Recognizesproblemofhealthilliteracy

TheParentintheOffice

Wouldliketobeheard
Wishestoberespected
Seekscredibleinformation
Wantscontrol;wantstomakedecision

StudiesofParents

Wanttheirchildrentobehealthy
Seektomakerationaldecisions
Weighbenefitsandrisks
Respecttheclinicianastrustedsource
Drawfromtheavailableevidence
Theirownexperiencewiththediseases
Theirownexperienceswiththevaccine
Whattheyhearfromthemedia,family,friends
Whattheyhearfromtheclinician

WhattheCDCRecommends

Taketimetolisten
Solicitandwelcomequestions
Acknowledgerisksandbenefits
Havebothscienceandstoriesavailable

TakeTimetoListen
Eyetoeyecontact
Notjustasyouspeak
Butalsoasyoulisten

Lettheparentfinishspeaking
Resisttheurgetomultitaskduringconversation

SolicitandWelcomeQuestions
Askforquestions
Conveythatyouhavetimetoanswerthese
Giveshortenoughanswersthatmoreiswelcome

AcknowledgeRisksandBenefits
Whileseveresideeffectshappen,theyarerare
TheVISlistsknownsideeffects
OKtonotethatnotvaccinatingisalsorisky

HaveBothScienceandStories
Available
Whileyoumayfeelsaferwithscientificinfo
Mostparentspreferexperiencesyoucanshare

TheC.A.S.E.forVaccines

Anewmodelfortalkingtoparents
Amnemonictoorganizearapid,usefulresponse
DrawsfromAristotelianteachingonrhetoric
CreatedbyAlisonSinger,MD
President
AutismScienceFoundation

Lackspublishedstudiesofitsefficacy
Nonethelesshasfacevalidity,historicalroots
Lackscompetingalternatives

TheCASEAcronym

Corroborate
AboutMe
Science
Explain/Advise

TheCASEApproach
Corroborate:
Acknowledgetheparentsconcernandfindsomepointon
whichyoucanagree;setthetoneforarespectful,successful
talk

AboutMe:
Describewhatyouhavedonetobuildyourknowledgebaseand
expertise

Science:
Relatewhatthesciencesays

Explain/Advise:
Explainyouradvicetopatient,basedonthescience

BreakUpinTwos
Corroborate:
Acknowledgetheparentsconcernandfindsomepointon
whichyoucanagree;setthetoneforarespectful,
successfultalk
WHAT PHRASING HAVE
YOU FOUND HELPFUL
WHEN A PARENT
HESITATES ABOUT
ANYTHING?

Corroborate
Whatisyourmainconcern?
Dontpermitavaguerefusal
Maketheparentgetspecific

Then
That'savalidconcern
WhenIheardthat,Isoughtoutanswersmyself
Webothwantyourchildtobefreeofillnessand
injury
Webothwanttoavoidunnecessarymedications
andtheirsideeffects

BreakUpinTwos
AboutMe:
Describewhatyouhavedonetobuildyourknowledge
baseandexpertise

DO YOU EVER TALK

ABOUT THIS SORT OF
THING WITH YOUR
PARENTS? WHAT HAVE
YOU SAID?

AboutMe
Imcommittedtoyourchildshealth,andIve
dedicatedmycareertothatwork
Ivebeenstudyingmedicineandpediatrics
nowforX years
OneoftheareaswhereIreadagreatdealis
aboutinfections,immunity,andvaccination
Vaccinationsrepresentamajorpartofmy
professionaleffortasyourchildspediatrician

BreakUpinTwos
Science:
Relatewhatthesciencesays

DO YOU TALK ABOUT

THE SCIENCE TO YOUR
PATIENTS PARENTS?
HOW DO YOU
INTRODUCE THAT?

Science
Vaccinesarebetterstudiedthananyother
medicineIprescribeortestIorder
EachvaccineissaferthananymedicineI
prescribe
Vaccinesarenotfoolproofbuttheyarethe
mosteffectivemeanstopreventcertain
injuriesandillnesses
Thedecisionwhattogivewhenisbasedon
thevaccineseffectiveness,safety,andspecific
needforthechildatthatparticularage

BreakUpinTwos
Explain/Advise:
Explainyouradvicetopatient,basedonthe
science

WHATS YOUR BOTTOM

LINE? HOW DO YOU
PHRASE YOUR
RECOMMENDATIONS?

Explain/Advise
ThatswhyIamrecommendingthisvaccine
Ifthisweremychild,Iwouldbevaccinating
hertoday
Igotthisvaccine
Imadesuremychildrengotthesevaccines
ThatswhyifIwereyou,Iwouldbegetting
thesevaccinesforyourchild

CisforCorroborate
YouandIultimatelywantthesamethingfor
yourchild.
Wewantyourchildhealthandfreeof
diseaseandinjury.
Iknowyouareworried,scared.
Itismyjobtohelpyouwithyourconcerns.

AisforAboutMe
Iamaprofessionalnotonlycommittedto
that,buttrainedandeducatedinthescience
ofhealthandmedicine.
Thatincludesvaccination.
Myexpertiseiswhyyoucametoseeme.

SisforScience
ThevaccinesIamrecommendingarethe
vaccinesIbelieveyourchildneeds.
Thesevaccineshavebeenprovenboth
effectiveageaswellassafeforchildrenyour
child'sage.

EisforExplain/Advise
Hereismyadvice:getthisvaccinetodayits
safe,itseffective,andyourchildwillbenefit
Ifyourchildweremine,Iwoulddothis.
Infact,doingsomaybemorevaluabletoyou
thananythingelsewedointhisvisit.

ThreeCommonConcerns
Vaccinesmaycauseautism
Toomanyvaccinestoosoonisharmful
Thevaccine(s)isnolongernecessary

TheCASEagainstAutism
Corroborate:
TherescertainlybeenalotonTVandtheinternet
aboutvaccinesandautismsoIcanunderstandwhy
youhavequestions

AboutMe:
IalwayswanttomakesureImuptodateonthe
latestinformationsothatIcandowhatsbestformy
patients,soIveresearchedthisthoroughly.
Infact,Ijustreturnedfromaprofessionalconference
whereexpertsreviewedtheactualevidence

MoreAgainstAutism
Science:
Theevidencedoesnotsupportthatmeasles
vaccine,theMMR,oranyvaccinecausesautism.
TheCDC,theAAP,theNIH,theIOM,andothers
haveallreviewedthedata
Allreachedthesameconclusion.
Dozensofstudieshavebeendone.
Noneshowalink.

FinishingtheCASEagainstAutism
Explain/Advise:
Vaccinesarecriticaltopreventingdeath,disease,
anddisability.
Theypreventdiseasesthatcauserealharm.
Choosingnottovaccinatedoesnotprotect
childrenforautism,butdoesleavethematriskfor
disease.
Childrenneedthesevaccines.

TheCASEagainstVaccineOverload
Corroborate:
Childrentodaycertainlygetmoreshotsthanthey
didyearsago.

AboutMe:
OurpracticefollowstheCDCschedulebecauseit
iscarefullydesignedtoprotectchildrenatthe
timetheyaremostvulnerabletodisease.
Ivereadthroughtherecommendations
carefully

MoreagainstVaccineOverload
Science:
Althoughchildrengetmoreshotstoday,they
actuallyreceivefewerimmunereactiveantigensthan
whentheygotfewershots,becausetechnologyhas
enabledustomakevaccinesthathaveonlythepart
ofthecellthatinducesimmuneresponse.
Plus,theimmunologicalchallengefromavaccineis
nothingcomparedtowhatkidsfightoffeveryday.
Anearinfectionisabiggerimmunological
challenge.

FinishingUpagainstOverload
Explain:
Wewantallthekidsinourpracticetobe
immunizedsothattheyhavethegreatestchance
foralong,healthylife.
Ifyourdaughterweremydaughter,andIwas
sittinginyourshoes,holdingherinmylap,I
wouldbegettinghervaccinatedtoday.

TheCASEagainstUnnecessary
Corroborate:
Icanunderstandwhyyoumightfeelthatway.
Mostofthetimewhenourchildrengettheflu,
wedonttestforit,andsoparentsdontknow
whentheirchildrenhavehadtheflu.

MoreagainstUnnecessary
AboutMe:
Iusedtothinkthatchildrennevergottheflubut
thestudiesarecompelling.
Inretrospectthosesorethroatswithfeverwith
negativestreptestingwereoftentheflu.
Samethingwiththevirusesleadinguptoear
infections
Samethingwithfeversandcoughsthatmadeus
worryaboutpneumonia.

MoreagainstUnnecessary
Science:
Thehospitalizationratesininfantslessthan2
duetotheflurivaltheratesintheelderly
Morethan40%ofschoolchildrengetthefluon
averageeveryyear
Thevaccineworksreallywell;itreducestherisk
by45to90%dependingontheyear

FinishingUpagainstUnnecessary
Explain:
Wecareaboutourpatientsanddontwantto
practicesubstandardcare.
Allourpatientsneedtobevaccinatedagainstthe
flu.
Mychildrenarefullyvaccinated.
Iamtoo.

TheCASEApproach
Corroborate:
Acknowledgetheparentsconcernandfindsomepointon
whichyoucanagree;setthetoneforarespectful,successful
talk

AboutMe:
Describewhatyouhavedonetobuildyourknowledgebaseand
expertise

Science:
Describewhatthesciencesays

Explain/Advise:
Giveyouradvicetopatient,basedonthescience

ClassicAristotelianRhetoric
AristotletaughttheCASEmethod
Topersuadeoneneedsmorethanjustevidence
Needthreethings
Logos (theinformationandreasoningyouhave)
Pathos (yourpassion,compassion,andconviction)
Ethos (yourprofessionalstandingw/theparent)

Rationale
Informationaloneinsufficient
Itsanemotionalinformationtoo
Oneneedstofeelgoodaboutthedecision
Onehastofeelstronglyaboutthedecision

Yourroleismorethanjustatechnicians

TheCASEApproach
Corroborate:
Acknowledgetheparentsconcernandfindsomepointonwhich
youcanagree;setthetoneforarespectful,successfultalk
(PATHOS)

AboutMe:
Describewhatyouhavedonetobuildyourknowledgebaseand
expertise(ETHOS)

Science:
Describewhatthesciencesays(LOGOS)

Explain/Advise:
Giveyouradvicetopatient,basedonthescience(PATHOS)

YourSourcesofInformation
Parentswantmorethaninformation
Wantstotrustyoubecauseofwhoyouare(ethos)
Expectsyoutohavepassionforwhatyouadvise
(pathos)

Youontheotherhandwantdatayoucantrust
Whataretheactualrecommendations?
Whatarethedatathatsupportthese?
Wherecanyoufindinformationtosupportyour
CASE?

SourceofRecommendations
AdvisoryCommitteeonImmunizationPractices
(ACIP)
Groupofvolunteerexperts
Meetsthreetimesayear
OrganizedbyCentersforDiseaseControland
Prevention(CDC)
Solesourceoffederalvaccinerecommendations
forcivilianpopulation
Thefederalgovernmentdoesnotrequirevaccines
Schoolanddaycaremandatesarestatebased

ACIPRecommendations

2012Child&AdolescentImmunizationSchedule
UpdatedatleastannuallyinJanuary
Providescatchupscheduletoo
Publishedwidelyindozensofjournals
AvailableonlinefromtheCDCVaccinessite
www.cdc.gov/vaccines

AAPandAAFPharmonizewithCDCACIP
AlsopublishestheAdultSchedule

VaccineSpecificDetails
ACIPpublishesitsrecommendationsinMMWR
Theseprovidedetails
Doseandroute
Timingvariationsandexceptions
Contraindicationsandprecautions
Otherissues
Basisforrecommendations
Wellreferenced

KnowhowtofindthemstartingatCDCvaccines

SpecificAdvicereParents
UnderstandingVaccinesandVaccineSafety
ResourcesforVaccineConversations
Factsheetsprovideinformationaboutvaccine
testing,safety,monitoring,andtheprocessfor
establishingtheUSimmunizationschedule
Letsfinditandreviewitscontents
StartattheCDCvaccinessite
www.cdc.gov/vaccines

CDCInformation
Dontplanonprintingandgivingtoparents
Dontplanonemailingthemthelinks
InsteadreadandremembertomakeyourCASE

OtherSources
AAPProviderResources
www2.aap.org/immunization
AAPParentResources
www.healthychildren.org
IACProviderResources
www.immunize.org
MNAAP
www.mnaap.org

Summary
Persuaderatherthaninform
CASE
CorroborateAboutMeScienceExplain/Advise

AristotelianRhetoric
PathosEthosLogosPathos

Knowyoursourcesofinformation
ACIPanditsrecommendations
CDCanditsresources